Amani Jambhekar, MD, Josue Chery, MD, John O’Laughlin, MS, Piotr Gorecki, MD. New York Methodist Hospital.
Background: Port site metastases have been reported after laparoscopic resection of intra-abdominal malignancies. It is a rare phenomenon, as such, the true incidence is not known. While there have been case reports of port site metastasis for gallbladder and colorectal cancer, review of the literature reveals only two previously reported cases of port site metastasis after laparoscopic surgery for gastric adenocarcinoma.
Case Report: A 71- year old female with a past medical history of hypertension and diabetes mellitus presented with anemia, black tarry stools, generalized weakness, malnutrition and unintentional weight loss associated with vomiting. Upper endoscopy examination revealed a large bleeding and obstructing mass that extended along the lesser curvature of the stomach, from the body to the antrum. Endoscopic ultrasound revealed a T3N2 lesion and the biopsy confirmed the diagnosis of adenocarcinoma. The patient underwent an uneventful laparoscopic D2, R0 near total gastrectomy with Roux en Y gastrojejunostomy. Intraoperatively, a large 9.5 cm mass was observed, that was infiltrating serosa with no evidence of metastatic disease. There was no tumor cell spillage or compromise in the principles of oncological tissue handling. Pathology revealed 6 out of 40 lymph nodes involved with carcinoma and clear margins. The patient’s recovery was uneventful and adjuvant chemotherapy was administered. Ten months after surgery, the patient presented with palpable subcutaneous nodules at the right and left subcostal 12-mm port sites. The paramedian incision from which the specimen was extracted within protection of the plastic bag was well healed without any lesions. Fine needle aspiration confirmed metastatic gastric adenocarcinoma. Subsequent CT of the abdomen and pelvis confirmed the isolated two port site nodules without evidence of distant metastases. The patient was treated with another cycle of chemotherapy after which the proton emission tomography (PET) scan did not show any other metastases and the size of the lesion was stable. The patient underwent resection of right upper quadrant abdominal mass with peritoneal biopsy and cytology. Intra-operative findings of the left upper quadrant nodule revealed infiltration of the mass to the left colon and metastatic deposit in the umbilical port site with no other metastases. Cytology was performed on 30 ml of clear peritoneal fluid and was negative for malignant cells. Currently the patient is recovering well in anticipation for adjuvant treatment and evaluation for possible second intervention.
Discussion: Port site metastases remain an infrequent clinical problem and are usually consequence of advanced peritoneal malignancy. We report on a case of advanced gastric malignancy, treated with laparoscopic gastrectomy with subsequent development of multiport metastatic disease and no evidence of distant metastases. The pathophysiology and the management of port site metastasis remain unclear.
Conclusion: Report of this rare clinical occurrence adds to the existing literature of this poorly understood phenomenon. Further studies are necessary to explore the pathogenesis of port site metastases and to elucidate the role of chemotherapy and potential benefit of subsequent surgical intervention. Photographs and radiograms will be presented.