Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy

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Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy Article in Acta chirurgica iugoslavica · August 2012 DOI: 10.2298/ACI1201105R · Source: PubMed

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UDK 616.366-06.04-089 DOI: 10.2298/ACI1201105R

/PRIKAZ SLU^AJA

Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy ........ .................................

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Zoran J.Ra‘natovi}2, Nemanja D. Zari}2, Danijel A. Galun2, Neboj{a S.Leki}2, Marjan Micev1,2, Vladimir R. Djordjevic2, Ljubomir M. Djurašic3, Mirko D. Kerkez1,2 1 The Faculty of medicine, University of Belgrade, Serbia 2 Clinic for digestive diseases -First surgical clinic, Clinical center of Serbia, Belgrade, Serbia 3 Clinic for Physical medicine and rehabilitation, Clinical center of Serbia, Belgrade, Serbia

Laparoscopic cholecystectomy is a surgical procedure of choice for benign gallbladder diseases. In about 1-2% of cases histopathological examination demonstrate incidental gallbladder cancer (GBCA). We report a case of a 61 year old woman who developed port site metastases after laparoscopic cholecystectomy for adenocarcinoma of the gallbladder. Metastases appeared on all four port sites. Review of literature regarding incidental GBCA an port site metastases was also performed. We conclude that the retrieval bag should be routinely used in laparoscopic cholecystectomy; the procedure should be performed with minimal trauma; in cases of incidental GB carcinoma, full thickness excision of the abdominal wall of the port sites demands additional studies; additional liver bed excision and local lymphadenectomy for T1b carcinoma are yet to be considered. Key words: incidental gallbladder carcinoma; port-site metastases; laparoscopic cholecystectomy

INTRODUCTION

L

aparoscopic cholecystectomy (LC) is a surgical procedure of choice for benign gallbladder diseases. In about 1-2% of cases histopathological examination demonstrate incidental gallbladder cancer (GBCA)1. Dissemination of malignant cells is potential risk in these conditions as it results from aspiration, trauma and spilling the contents of the gallbladder, pneumoperitoneum and during the extraction through a narrow opening in the abdominal wall. The prognosis of the incidental gallbladder carcinoma depends primarily on the stage, histologic grade, surgical margins, lymphatic, vascular and/or perineural spread of the tumor.

CASE REPORT A 61 year old female patient with abdominal pain and nausea was admitted to the hospital. Abdominal ultrasound demonstrated gallbladder calculosis, without apparent thickening of the wall. Serum levels of tumor markers CEA and CA 19-9 were normal. The patient underwent laparoscopic cholecystectomy. The gallbladder was removed via umbilical port without using the retrieval bag, and abdominal drain was placed through right lateral port. Postoperative course was uneventful. The drain was removed on the first postoperative day, and the patient was discharged from the hospital on the second postoperative day. On a regular follow up one month following surgery the patient was without signs and symptoms of postoperative complications. Histopathology finding of the gallbladder was infiltrative adenocarcinoma of gallbladder (TNM:T3 Nx Mx L1 V1), grade III. The patient was informed about the necessity for additional surgical procedure, but the patient refused further surgical treatment. Eleven months after the surgery the patient was readmitted because of a tumor like lump in the area of umbilical port (Figure 1). Laboratory analysis and serum levels of tumor markers CEA, CA 19-9, AFP were in normal range. The patient was operated and surgical procedure included biopsy of the liver bed, excision of metastatic lump and round ligament of the liver (Figure 2) and reconstruction of the anterior abdominal wall defect. Histopathology of the liver bed biopsy was benign. Histopathology of the tumor of the anterior abdominal wall was metastatic adenocarcinoma originating from the gallbladder. (Figure 3) Eighteen months after LC the patient was readmitted because of the lump in the area of right lateral port, used for abdominal drainage.

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FIGURE 1. CT FINDINGS ELEVEN MONTHS AFTER LAPAROSCOPIC CHOLECYSTECTOMY

FIGURE 2. PORT-SITE METASTASIS

The serum levels of the tumor markers were in normal range, and there was no evidence of liver metastasis. The patient was operated and the lump was removed. Histopathology examination confirmed a metastatic adenocarcinoma originating from the gallbladder. Finally, 24 months after LC the patient was presented with metastasis in the area of epigastric port site. The patient refused further surgical treatment. The patient died 28 months after LC. DISCUSION The diagnosis of the gallbladder cancer in the early stages is usually incidental. The disease is presented with typical symptoms of cholelithiasis or cholecystitis. Because of the anatomical characteristics of the region, the disease usually progresses rapidly. The radiological appearance of gallbladder carcinoma include focal or diffuse gallbladder wall thickening, intraluminal polypoid mass, porcelain

FIGURE 3. PORT-SITE METASTASIS OD GALLBLADDER ADENOCARCINOMA gallbladder and the tumor projection in the liver bed.2 Such findings would require an open procedure. In about 1% of cases, the gallbladder carcinoma is incidental finding during histopatologic analysis following laparoscopic cholecystectomy. The choice for additional surgical intervention in cases of incidental gallbladder carcinoma depends primarily on the tumor stage (Table 1, 2). It is believed that tumor stage pT1b requires a minimum of liver bed excision and regional lymphadenectomy. Tumors of stage >pT2 requires a resection of segments IV and V of the liver or right hepatectomy with regional lymphadenectomy. In case of the positive resection line on the cystic duct, it is necessary to perform resection of extrahepatic bile duct.3 Shirai et al.4 reported a 5 year survival on a sample of 80 patients who underwent no additional interventions: in pT1 - 100%; in pT2 40%; and in pT3 - 0%. However, some authors propose radical second wedge resection for T1b carcinoma of the gallbladder. Goetze et al5 analyzed 124 patients with T1 cancer with a 5-year survival of 48 % and founded that extended re-resection have increased the 5-year survival up to 68 % for T1 incidental gallbladder carcinoma. Analysis shows a statistically significant survival benefit for re-resection of T1b cancers from 34% to 75%. Further prospective studies are necessary to support this proposition.(Table 1, 2)

Br. 1

Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecistectomy

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TABLE 1 TNM CLASSIFICATION OF GALLBLADDER CARCINOMA WITH SUGGESTED SURGICAL APPROACH FOR INCIDENTAL GALLBLADDER CARCINOMA AFTER LC Stage

TNM definitions

Suggested surgical approach

pT1

Tumor invades lamina propria or muscle layer

Wide local excision of abdominal wall around exit port

pT2

Tumor invades the perimuscular connective tissue; no extension bezond the seroca or into the liver

Wide local excision of abdominal wall around exit port with liver bed excision and regional lymphadenopathy

pT3

Tynir oerfirates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as stomach, duodenum, colon or pancreas, omentum or extrahepatic bile duct

Wide local wxcisiuon of abdominal wall around wxit port with radical second operation (liver resection with lymphadenectomy)

pT4

Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures

Wide local excision of abdominal wall around exit port with radical second operation (liver resection with lymphadenectomy)

TABLE 2 AJCC STAGE GROUPINGS Stage 0 Stage IA Stage IB Stage IIA Stage IIB Stage III Stage IV

Tis, N0, M0 T1, N0, M0 T2, N0,M0 T3, M0, N0 T1, N1, M0 T2, N1, M0 T3, N1, M0 T4, any N, M0 Any T, Any N, M1

There are numerous reports of the incidental gallbladder carcinoma detected after laparoscopic cholecystectomy with postoperative port-site metastasis.6-9 Maker et al.10 in their study which included 113 patients have found that the incidence of port-site metastases after LC for GBCA is up to 40%. However, there is no consensus regarding the patophysiological mechanisms of metastases. Assumptions include trauma and spilling the contents of the gallbladder, the dissemination of malignant cells during the extraction through a narrow opening in the abdominal wall or via the abdominal drain, pneumoperitoneum and CO2 insufflation. (Table 3) Since Drouard first described port site metastasis twenty years ago11 different theories on pathophysiological mechanisms have been proposed. Drouard believed that evacuation of gallbladder through the umbilical port is primary mechanism and many authors followed his opinion. Perforation and spillage during LC increases the incidence of port site metastases from 9% - 40%.12 Goetze et al. re-

ported a trend toward a lower rate of port-site metastases for patients with perforation of gallbladder who are operated under the protection of retrieval bag compared with those without a bag, and they are proposing routine use of retrieval bag, before perforation has occurred.13 However, in situations where doubt does exist, there is a question of the necessity of converting to open cholecystectomy. We think that the primary pathological mechanism of metastatic dissemination of malignant cells was direct dissemination during the extraction of the gallbladder as well as spreading of tumor cells along the abdominal drain. However, we cannot with certainty exclude the role of pneumoperitoneum and its impact on the growth of malignant cells. Cirroco14 and associates reported four patients who underwent laparoscopic operation for primary colon cancer in which there was not only the development of metastases in the port where the resected colon was extracted, but also on all other ports. In our case the second abdominal wall metastasis presented 6 months after radical excision of the metastatic tumor in the umbilical region of the abdominal wall was positioned laterally, in place of right lateral port; and third metastasis presented 24 months after LC. We can presume that that the second metastasis occurred because of the direct spreading of malignant cells along the abdominal drain, although the interval of 18 months after LC seems too long, but there is no explanation of the third metastasis other then the influence of pneumoperitoneum. It seems that port site metastases are a result of multiple factors which include direct dissemination of malignant cells, pneumoperitoneum, local trauma, histopatologic properties of the tumor, as well as skill of the surgeon. Due to technical limitations, we did not use removal bag during the operation, but we are recommending that it should be routinely used during LC. The open question in the literatu-

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TABLE 3 CASE REPORTS OF PORT SITE METASTASIS OF INCIDENTAL GALLBLADDER CARCINOMA AFTER LC Author

Year

Age

Sex

Interval

Implants

Localization

Tumor stage

Follow-up

Ra‘natovi}

2012

61

F

11,18 and 24 months

2

Extraction port, right lateral and epigastric port

T3 Nx Mx G3

28 m, died

Drouard

1991

58

F

3months

1

Extraction port

T3 Nx M0

7 m, alive

Gornish

1991

53

F

4 months

2

Extraction port

T3 Nx M0

6 m, died

Barsoum

1992

73

F

3 months

2

Extraction port

T3 Nx M0

6 m, died

Pezet

1992

58

F

4 monts

2+L+p

Extraction port

T3 Nx M0

10 m, died

Walsh

1993

88

F

4 monts

1

Right lat. port

T3 Nx M0

6 m, died

Kim

1994

59

F

2 weeks

1

Extraction port

Nally

1994

69

F

7 months

1

Extraction port

T3 Nx M0

15 m, died

Targarona

1994

61

F

-

1

Extraction port

T3 Nx M0 G3

died

Weiss

1994

41

F

14 weeks

1+L

Extraction port

T3 Nx M0 G3

-

Mori

1997

63

M

12 months

1

Extraction port

T3 G1

22 m, alive

Ohmura

1999

71

F

30 monts

1

Extraction port

T3 N0 M0

26 m, alive

re is whether the port-site metastases should be considered as complication of laparoscopic cholecystectomy. Figueiras et al.15 position supports this attitude, but Paolucci in his studies that included 174 patients16 and 149 patients17 concluded that there was no statistically significant difference regarding the incidence of port-site metastases between laparoscopic and open cholecystectomy; therefore we think that port-site metastases should not be classified as postoperative complication of LC. The fact that 24 months following LC the patient was without signs of local recurrence or liver metastases, with port-site metastasis appearing 11, 18 and 24 months following surgery, suggests that histopathologic properties of the tumor may have a prognostic value. Whether the precise location of the tumor, T3 carcinoma infiltrating liver parenchyma or T3 carcinoma localized on the opposite side, without infiltrating the surrounding structures have any prognostic difference remains an open question to be answered in future studies. CONCLUSION We conclude that the retrieval bag should be routinely used in laparoscopic cholecystectomy; the procedure should be performed with minimal trauma; in cases of incidental GB carcinoma, full thickness excision of the abdominal wall of the port sites demands additional studies; additional liver bed excision and local lymphadenectomy for T1b carcinoma are yet to be considered.

12 m, alive

SUMMARY MULTIPLE PORT-SITE METASTAZE INCIDENTALNOG KARCINOMA @U^NE KESE NAKON LAPAROSKOPSKE HOLECISTEKTOMIJE Laparoskopska holecistektomija je hirurška procedura izbora za benigna oboljenja ‘u~ne kese. U oko 1-2% slu~ajeva incidentalno se dijagnostikuje karcinom ‘u~ne kese. Prikazujemo slu~aj pacijentkinje sa multiplim metastazama adenokarcinoma ‘u~ne kese na mestima svih portova nakon laparoskopske holecistektomije. Takodje smo uradili pregled aktuelnih radova na temu incidentalnog karcinoma ‘u~ne kese i port-site metastaza. Zaklju~ujemo da kesu za ekstrakciju ‘u~ne kese uvek treba koristiti; proceduru treba sprovesti sa minimalnom traumom; potrebna su dopunska ispitivanja o neophodnosti ekscizije mesta portova nakon incidentalnog otkrivanja karcinoma ‘u~ne kese; dodatna ekscizija lo‘e ‘u~ne kese i lokalna limfadenektomija za T1b karcinome ‘u~ne kese zahteva dodatna istra‘ivanja. Klju~ne re~i: karcinom ‘u~ne kese, port-site metastaze; laparoskopska holecistektomija REFERENCES 1. Cucinotta E, Lorenzini C, Melita G, Iapichino G, Curro G. Incidental gallbladder carcinoma: does the surgical approach influence the outcome? ANZ J Surg. 2005;75: 795-798.

Br. 1

Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecistectomy

2. Levy AD, Murakata LA, Rohrmann CA. Gallbladder carcinoma: radiologic-pathologic correlation. RadioGraphics. 2001;21:295-314. 3. Shimizu T, Arima Z, Zokomuro S et al. Incidental gallbladder cancer diagnosed during and after laparoscopic cholecystectomy. J Nippon Med Sch. 2006;73:136140. 4. Shirai Y, Yoshida K, Tsukada K, Muto T. Inapparent carcinoma of the gallbladder: An appraisal of a radical second operation after simple cholecystectomy. Ann Surg. 1992;215:326-331. 5. Goetze TO, Paolucci V. Immediate radical re-resection of T1 incidental gallbladder cancer and the problem of an adequate extenst of resection(results of the German registry "Incidental Gallbladder Cancer"). Zentralbl Chir. 2011, Mar 1 (Epub ahead of print). 6. Singla S, Singla S, Budhiraja S. Port site metastasis after laparoscopic cholecystectomy. Indian J Surg. 2009; 71:41-42. 7. Genc V, Onur Kirimker E, Akyol C, Kocaay AF, Karabork A, Tuzuner A, Erden E, Karayalcin K. Incidental gallbladder cancer diagnosed during or after laparos-copic cholecystectomy in members of the Turkish population with gallstone disease. Turk J Gastroenterol. 2011; 22:513-6. 8. Mitrovi} F, Krd‘ali} G, Musanovi} N, Osmi} H. Incidental gallbladder carcinoma in regional clinical center. Acta Chir Iugosl. 2010;57:95-7. 9. Fuks D, Requmbeau JM, Le Treut YP, Bachellier P, Raventos A, Pruvot FR, Chiche L, Farges O. Incidental gallbladder cancer by the AFC-GBC-2009 Study Group. World J Surg. 2011;35:1887-97. 10. Maker AV et al. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol; published online 23 June 2011. 11. Drouard F, Delamarre J, Capron JP. Cutaneous seeding of gallbladder cancer after laparoscopic cholecys-tectomy. N Engl J Med. 1991;325:1316. 12. Z’graggen K, Birrer S, Maurer CA, Wehrli H, KlaiberC, Baer HU. Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsus-pected gallbladder carcinoma. Surgery. 1998; 124:831-8. 13. Goetze T, Paolucci V. Use of retrieval bags in incidental gallbladder cancer cases. World J Surg 2009; 33:2161-2165. 14. Cirroco WC, Shwarttman A, golub RW. Abdominal wall recurrence after laparoscopic colectomy for colon cancer. Surgery. 1994;116:842-846. 15. Garcia Figueiras R, Diaz Tie M, Lapena Villaroya JA, Armesto Fernandez MJ, Gonzales Rodriguez AA, Arguelles Pintos M. Port site mestastases after laparoscopic cholecystectomy for un unexpected gallbladder carcinoma. Abdom Imaging. 1999;24:404-406. 16. Paolucci V. Port site recurrences after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2001;8: 535-543. 17. Paolucci V, Neckell M, Goetze T. Unsuspected gallbladder carcinoma - the CAE-S/CAMIC registry. Zentralbl Chir. 2003; 128:309-12.

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