|Year : 2019 | Volume
| Issue : 1 | Page : 47-50
Case series on abdominal wall implantation malignancy
Rituparna Biswas, Anirban Halder
Department of Radiotherapy, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
|Date of Web Publication||14-Mar-2019|
Dr. Anirban Halder
3rd Floor, F 35 A/1, Gautam Nagar, New Delhi - 110 049
Source of Support: None, Conflict of Interest: None
Abdominal wall implantation malignancy or scar recurrence following laparotomy or laparoscopy is a rare and untoward occurrence. We present here a case series of five patients who developed scar malignancies, of which four patients underwent open abdominal surgery while the other had laparoscopic surgery.
Keywords: Implantation, laparoscopy, open surgery, recurrence
|How to cite this article:|
Biswas R, Halder A. Case series on abdominal wall implantation malignancy. J Mahatma Gandhi Inst Med Sci 2019;24:47-50
| Introduction|| |
Although abdominal wall implantation malignancy is relatively rare event, an increasing interest in the topic of abdominal wall wound recurrences has followed the surge of minimally invasive surgery, principally due to concerns regarding early reports of an increased risk of port site and incisional wound metastases associated with pneumoperitoneal technique (Berends 1994). Implantation malignancy in the abdominal wall after open surgery is rare and has been reported mostly after resection of colorectal carcinoma and hepatocellular carcinoma. True extent of problem is difficult to determine. Still, there are number of reports suggesting far more occurrence of port site malignancies as compared to wound recurrence following open surgeries (Paolucci, Schaeff, Schneider, and Gutt, 1999).
We report here a case series of five patients with abdominal wall implantation malignancies, and four among them presented with wound recurrences following open surgeries.
| Case Reports|| |
A 65-years-old male who was suffering from pain upper abdomen for 2 years eventually was diagnosed to have multiple gallbladder (GB) calculi, for which he underwent laparoscopic cholecystectomy (LC). Histopathologic examination (HPE) revealed adenocarcinoma GB involving entire wall extending into serosa with no perineural invasion. The patient developed pain upper abdomen and an ulceroproliferative, nonhealing growth at the epigastric region, 2 weeks after surgery, exactly at the site through which laparoscopy port was introduced [Figure 1]. HPE of specimen obtained from growth revealed metastatic adenocarcinoma. The patient was planned for six cycles of chemotherapy with gemcitabine and cisplatin, but he was lost to follow-up after two cycles of chemotherapy.
A 45 years -old female underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for dysfunctional uterine bleeding (DUB) at a remote hospital without prior biopsy or abdominopelvic imaging, following which she developed a swelling over the left side of scar line within a span of 1 month which was increasing in size [Figure 2]; at this point of time, she was presented to us at our department. Contrast-enhanced computed tomography (CECT) scan of the whole abdomen revealed a residual mass 74 mm × 46 mm in the cervix with invasion up to the right parametrium but not up to lateral pelvic wall. Right internal iliac lymph node and paraaortic lymph nodes were enlarged, and multiple metastatic deposits were present in the lower abdominal wall. HPE from cervical growth showed features of moderately differentiated squamous cell carcinoma. Fine-needle aspiration cytology (FNAC) from abdominal scar nodule showed features of metastatic squamous cell carcinoma. Meanwhile, the nodule size increased over time and finally fungated into a large 12 cm × 10 cm ulceroproliferative, foul-smelling mass. Palliative radiotherapy of 20 Gy in 5 fractions over 1 week was given to abdominal wall growth, and then, she was planned for six cycles of palliative chemotherapy with paclitaxel and carboplatin but she succumbed to death after four cycles.
A 40-years-old female underwent abdominal hysterectomy with bilateral salpingo-oophorectomy for DUB following which she developed pain and swelling over the left side of incision line after 1 year. On examination, 4 cm × 3 cm hard, mobile, nontender swelling was found over the left side of incision scar line. Per vaginal examination revealed hard, indurated 2 cm × 2 cm mass felt on the right side of vault which bleeds on touch. Biopsy from vaginal vault showed moderately differentiated infiltrating, nonkeratinizing squamous cell carcinoma. FNAC from scar nodule had also been done which revealed metastatic poorly differentiated carcinoma. She received concurrent chemoradiation to the whole pelvis (50 Gy in 25 fractions over 5 weeks with weekly cisplatin) followed by intravaginal brachytherapy and boost to skin nodule with dose of 16 Gy in 8 fractions over 1.5 weeks by 9 MeV electrons. The patient responded well and was followed up subsequently.
A 32-years-old male underwent suprapubic cystolithotomy due to obstructive uropathy and ultrasonography (USG) evident calculus within urinary bladder; cystoscopy and USG did not reveal any neoplastic growth within bladder. Then, he presented with gradually increasing swelling at scar site after 3 months [Figure 3]. On evaluation, CECT scan abdomen showed large polypoidal multilobulated urinary bladder mass obliterating left ureteric orifice causing left-sided hydroureteronephrosis. No local infiltration outside bladder was noted, and fat planes were maintained. A separate swelling in the lower anterior abdominal wall was noted measuring 3 cm × 2 cm with well-defined margin. HPE of specimen obtained by transurethral resection of bladder tumor revealed nonmuscle invasive high-grade urothelial carcinoma. HPE report from abdominal wall swelling showed metastatic carcinoma probably transitional cell carcinoma. Local excision of the abdominal swelling was performed, and he then received six cycles of intravesical bacillus Calmette–Guerin and was followed up thereafter.
A 46-years-old female underwent open cholecystectomy for cholelithiasis. HPE suggested chronic cholecystitis. Then, she presented with an abdominal parietal mass measuring 8 cm × 6 cm with chronic discharging sinus at cholecystectomy scar site after 2 months [Figure 4]. USG upper abdomen revealed parietal abscess. CECT scan upper abdomen showed ill-defined heterogeneously enhancing space-occupying lesion in the right parietal wall with areas of necrosis inside causing infiltration of right rectus and abutting underlined peritoneal wall. Few satellite nodules were noted adjacent to main lesion. Excision biopsy from subcutaneous swelling showed metastatic adenocarcinoma. Specimen of cholecystectomy was reviewed which again revealed chronic cholecystitis. After extensive search through investigations also, no other primary lesion was found at any other possible sites. She received six cycles of palliative chemotherapy with gemcitabine and carboplatin. She then developed liver metastases following which she was administered capecitabine and oxaliplatin doublet chemotherapy. Unfortunately, her disease progressed and she died after four cycles.
| Discussion|| |
Abdominal wall metastases after surgery for malignancies are rare but described event: the reported series referred to gastrointestinal (Cook and Dehn, 1996), urological (Chueh, Tsai, and Lai, 2004), and gynecological malignancies such as endometrial carcinoma,, uterine leiomyosarcoma, and ovarian cancer. Two of our reported cases with underlying undiagnosed carcinoma cervix presented with scar site recurrence following abdominal hysterectomy. Most of the studies have been done on implantation malignancy following surgery for colorectal cancer. Abdominal wall metastases after open resection of colorectal cancer occur in 0.6%–2.5% of all patients.,, In the index series, four of our reported cases have developed scar site malignancies following open surgeries. Among urologic malignancies, the incidence of tumor seeding in general laparoscopic surgery ranges from 0.8% to 21%., However, most authors report an incidence of 0.8%–1.6% in conventional open methods.,, Our fourth reported case is a scar site implantation malignancy following suprapubic cystolithotomy in an unsuspected case of transitional cell carcinoma of urinary bladder. A number of variables affect the incidence of recurrences, including stage of tumor (typically found in advanced stage disease) and extent of manipulation during operation. Direct tumor cell seeding in the abdominal wound at the time of operation is thought to be most likely the cause of recurrence. Another much less likely explanation is hematogenous implantation. Because the liver and lungs receive all of the venous drainage from the abdominal organs before distribution to the rest of the body, it seems unlikely that the tumor would spread hematogenously to the abdominal wall without pulmonary or hepatic involvement.
Our first reported case is an abdominal wound recurrence following LC. LC is a proven, well-accepted surgical technique for the benign disease of GB. A potentially serious complication of LC is the inadvertent dissemination of the unsuspected GB carcinoma. Although the mechanism of the abdominal wall recurrence is still unclear, possible causes of tumor dissemination in laparoscopic surgery for cancer include tumor spillage from manipulation and instrumentation, perforation of GB, spurting of CO2 gas-containing tumor cells through the port site (so-called chimney phenomenon), and extraction of the specimen without an endobag. The true incidence of abdominal wall metastasis after LC is unknown. However, many authors reported no significant differences between laparoscopic and open surgery in the incidence of wound recurrence. They suggested that the biological aggressiveness of the disease was responsible for port site recurrence. Hence, port site metastasis from incidental malignancy should not discourage us from performing laparoscopic surgery. The use of slow desufflation, avoidance of GB perforation, avoidance of excessive manipulation and instrumentation, trocar site washout, specimen bag for retrieval of GB, and irrigation of abdomen with tumoricidal solutions may further decrease the incidence. However, we also present a case of scar site implantation malignancy following an open cholecystectomy.
| Conclusion|| |
The authors stress that caution should be observed during surgery to remove a malignant neoplasm to avoid parietal dissemination hence implantation malignancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]