J Gastrointest Canc DOI 10.1007/s12029-014-9622-y
CASE REPORT
Delayed Isolated Port-Site Metastasis of Gallbladder Cancer Following Laparoscopic Cholecystectomy: Report of Two Cases Mahesh Sultania & Durgatosh Pandey & Jyoti Sharma & Saumyaranjan Mallick & Asit Ranjan Mridha
# Springer Science+Business Media New York 2014
Introduction Laparoscopic cholecystectomy is the standard of care for gallstone disease [1]. The histopathological examination of all gallbladder specimens, though resected for gallstone disease, is recommended in order to detect the underlying gallbladder cancer [2]. The presence of incidentally detected gallbladder cancer following laparoscopic cholecystectomy, in most of the patients (except T1a tumors) warrants a completion radical surgery along with excision of port sites in order to lower the risk of locoregional and port-site metastasis [3]. Port-site metastasis usually manifests early following laparoscopic cholecystectomy, in the presence of underlying gallbladder cancer, and reflects an aggressive behavior of tumor; these patients are mostly not amenable to surgical treatment as they have associated disseminated peritoneal disease. We present two cases of delayed (more than 5 years) port-site metastasis following laparoscopic cholecystectomy; they were not diagnosed with gallbladder cancer at the time of cholecystectomy as their gallbladder specimens were not subjected to histopathological examination.
Case Reports Case 1 A 60-year-old lady presented to us with complaints of recurrent epigastric lump of 2 months in duration. She had M. Sultania : D. Pandey (*) : J. Sharma Department of Surgical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India e-mail: [email protected] S. Mallick : A. R. Mridha Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
undergone excision of the mass 3 months back in another hospital; histopathological examination of the mass revealed metastatic adenocarcinoma. She was referred to our hospital; however, she did not come to us initially. She also reported to have undergone laparoscopic cholecystectomy for gallstone disease 6 years back at another hospital. She denied to have been told about the histopathological examination of gallbladder specimen. She was not icteric. Abdominal examination revealed a 3×3 cm parietal mass in the epigastric region. Histopathological examination of core cut biopsy specimen of the lump confirmed metastatic adenocarcinoma. Radiological investigation showed epigastric mass without any other focus of disease (Fig. 1). In view of the recurrent disease, she was prescribed six cycles of Gemcitabine- and Oxaliplatin-based chemotherapy. Following chemotherapy, radical excision of the epigastric lump with mesh abdominoplasty was carried out. Intraoperatively, there was a 3×3 cm tumor in the anterior abdominal wall at the scar site. There was no evidence of disease in gallbladder fossa, and there were no liver, omental, or peritoneal deposits. Histopathology report showed moderately differentiated adenocarcinoma (Fig. 2); all margins were free of tumor. The tumor cells were immunopositive for cytokeratin (CK) 7 and 19, while negative for CK20. The CK7 and 19 co-positivity indicate that the tumors originate from simple glandular epithelium like hepatobiliary, lung, etc. CK20 negativity excludes tumors of the colon and rectum (Fig. 3). The combination of morphological picture and immunohistochemistry results was strongly suggestive of metastasis from the gallbladder primarily, especially in view of past laparoscopic cholecystectomy, recurrence at port site, and absence of any other site of disease. She was planned for postoperative radiotherapy with 45–50 Gy; however, she reported to have disseminated peritoneal disease and lung metastasis detected on PET-CT after 3 months of surgery. She was advised palliative treatment.
J Gastrointest Canc
Fig. 1 CECT of the abdomen. a, b Mass in the epigastric region. c, d Post cholecystectomy status with no residual disease in the gallbladder fossa and elsewhere
Case 2 A 35-year-old lady presented to us with a lump in the epigastrium at the port-site scar. She had undergone laparoscopic cholecystectomy for gallstone disease 5 years ago at another hospital. She also denied to have been told about the histopathological examination of gallbladder specimen. Abdominal examination revealed a 4 cm×3 cm parietal lump in the epigastric port site. Contrast-enhanced computed tomography (CECT) scan of abdomen showed a parietal nodule which was indenting the liver and stomach, without invading these structures; the rest of the abdominal structures were normal. Histopathological examination of core cut biopsy
Fig. 2 a Microphotograph showing a tumor adjacent to skeletal muscle (H&E, ×40). b The tumor cells arranged in acini (×200)
specimen of the lump confirmed metastatic adenocarcinoma of gallbladder origin. She underwent radical excision of the epigastric lump with mesh abdominoplasty. Intraoperatively, there was a 5×4 cm tumor at the port site; there was no liver, omental, or peritoneal deposit, and the gallbladder fossa was clean. Histopathological examination of the resected specimen revealed metastatic adenocarcinoma in the abdominal wall, involving the muscle and subcutaneous tissue. Morphology was consistent with the primary gallbladder cancer. Though she was advised chemotherapy, she did not agree for it. She is asymptomatic after 3 years of follow-up.
J Gastrointest Canc
Fig. 3 Microphotograph showing that the tumor cells are a immunopositive for cytokeratin (CK) 7 (IHC, ×200), b immunopositive for CK19 (IHC, ×200), and c negative for CK20 (IHC, ×200)
Discussion Gallbladder cancer is often diagnosed incidentally on histopathological examination of the gallbladder specimen following cholecystectomy for a gallstone disease. These patients should undergo revision surgery if the muscularis layer is involved by the tumor (T1b or higher stage) [3, 4]. Recommendations and practices regarding port-site resection vary. While traditionally it has been recommended that all port sites be resected, recent data shows that port-site resection is not associated with improved outcome and should not be considered mandatory [5]. The author’s (DP) practice is to resect the port site through which the gallbladder was retrieved (usually the epigastric port). If this is not known, both epigastric and umbilical port sites are resected. Suspicion of gallbladder cancer during laparoscopic cholecystectomy being done for gallstone disease warrants conversion to open surgery in view of the high risk of port-site metastasis [6]. Patients who develop port-site recurrence following laparoscopic cholecystectomy do so within a short interval. Such patients usually have associated disseminated peritoneal diseases and have poor outcome [7]. A few long-term survivors who were treated for port-site recurrences following laparoscopic cholecystectomy for incidentally detected gallbladder cancer have been reported [8]. Delayed port-site metastasis is rarer; the longest duration between laparoscopic cholecystectomy and appearance of port-site recurrence reported so far in the literature is 4 years [9, 10]. Our patients presented with port-site recurrences after a long duration (more than 5 years) following laparoscopic cholecystectomy. Early recurrences at the port site may be associated more often with aggressive tumor biology and concurrent peritoneal metastases. Late recurrences, on the other hand, may be a manifestation of local tumor implantation at the port site during extraction of the gallbladder. Need of other port-site resection and doing completion radical cholecystectomy in such cases is questionable. In the above cases, resection was not done as recurrence may have been a manifestation of local tumor implantation. It
is recommended that gallbladder specimen should be extracted using a retrieval bag during laparoscopic cholecystectomy; compliance on the part of surgeons is poor due to cost and time factor. Moreover, retrieval bags also do not eliminate the possibility of local tumor cell implantation completely [11]. In conclusion, delayed port-site metastasis usually indicates localized disease and favors long-term survival in gallbladder cancer in contrast to early port-site metastasis which mostly indicates disseminated peritoneal disease. It cannot be overstressed that all the gallbladder specimens must be subjected to histopathological examination following cholecystectomy for gallstone disease.
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Garg PK, Teckchandani N, Hadke NS, Chander J, Nigam S, Puri SK. Alteration in coagulation profile and incidence of DVT in laparoscopic cholecystectomy. Int J Surg. 2009;7:130–5. 2. Siddiqui FG, Memon AA, Abro AH, Sasoli NA, Ahmad L. Routine histopathology of gallbladder after elective cholecystectomy for gallstones: waste of resources or a justified act? BMC Surg. 2013;13:26. 3. Reid KM, Ramos-De la Medina A, Donohue JH. Diagnosis and surgical management of gallbladder cancer: a review. J gastrointest Surg. 2007;11:671–81. 4. Abramson MA, Pandharipande P, Ruan D, Gold JS, Whang EE. Radical resection for T1b gallbladder cancer: a decision analysis. HPB (Oxford). 2009;11:656–63. 5. Maker AV, Butte JM, Oxenberg J, Kuk D, Gonen M. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol. 2012;19:409–17. 6. Fong Y, Brennan MF, Turnbull A, Colt DG, Blumgart LH. Gallbladder cancer discovered during laparoscopic surgery. Potential for iatrogenic tumor dissemination. Arch Surg. 1993;128: 1054–6. 7. Z’graggen K, Birrer S, Maurer CA, Wehrll H, Klalber C, Baer HU. Incidence of port site recurrence after laparoscopic cholecystectomy
J Gastrointest Canc for preoperatively unsuspected gallbladder carcinoma. Surgery. 1998;124:831–8. 8. Suzuki K, Kimura T, Hashimoto H, Nishihara T, Ogawa H. Port site recurrence of gallbladder cancer after laparoscopic surgery: two case reports of long-term survival. Surg Laparosc Endosc Percutan Tech. 2000;10:86–8. 9. Nakagawa S, Tada T, Furukawa S, Abe M, Hatakeyama K. Late-type recurrence at the port site of unexpected gallbladder carcinoma after a
laparoscopic cholecystectomy: report of a case. Surg Today. 2000;30: 853–5. 10. Jeon HM, Kim JS, Lee CD, Kim EK, Kim SN. Late development of umbilical metastasis after laparoscopic cholecystectomy for gallbladder carcinoma. Oncol Rep. 1999;6:283–7. 11. Paolucci V, Schaeff B, Schneider M, Gutt C. Tumor seeding following laparoscopy: international survey. World J Surg. 1999;23: 989–95.
CASE REPORT
Delayed Isolated Port-Site Metastasis of Gallbladder Cancer Following Laparoscopic Cholecystectomy: Report of Two Cases Mahesh Sultania & Durgatosh Pandey & Jyoti Sharma & Saumyaranjan Mallick & Asit Ranjan Mridha
# Springer Science+Business Media New York 2014
Introduction Laparoscopic cholecystectomy is the standard of care for gallstone disease [1]. The histopathological examination of all gallbladder specimens, though resected for gallstone disease, is recommended in order to detect the underlying gallbladder cancer [2]. The presence of incidentally detected gallbladder cancer following laparoscopic cholecystectomy, in most of the patients (except T1a tumors) warrants a completion radical surgery along with excision of port sites in order to lower the risk of locoregional and port-site metastasis [3]. Port-site metastasis usually manifests early following laparoscopic cholecystectomy, in the presence of underlying gallbladder cancer, and reflects an aggressive behavior of tumor; these patients are mostly not amenable to surgical treatment as they have associated disseminated peritoneal disease. We present two cases of delayed (more than 5 years) port-site metastasis following laparoscopic cholecystectomy; they were not diagnosed with gallbladder cancer at the time of cholecystectomy as their gallbladder specimens were not subjected to histopathological examination.
Case Reports Case 1 A 60-year-old lady presented to us with complaints of recurrent epigastric lump of 2 months in duration. She had M. Sultania : D. Pandey (*) : J. Sharma Department of Surgical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India e-mail: [email protected] S. Mallick : A. R. Mridha Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
undergone excision of the mass 3 months back in another hospital; histopathological examination of the mass revealed metastatic adenocarcinoma. She was referred to our hospital; however, she did not come to us initially. She also reported to have undergone laparoscopic cholecystectomy for gallstone disease 6 years back at another hospital. She denied to have been told about the histopathological examination of gallbladder specimen. She was not icteric. Abdominal examination revealed a 3×3 cm parietal mass in the epigastric region. Histopathological examination of core cut biopsy specimen of the lump confirmed metastatic adenocarcinoma. Radiological investigation showed epigastric mass without any other focus of disease (Fig. 1). In view of the recurrent disease, she was prescribed six cycles of Gemcitabine- and Oxaliplatin-based chemotherapy. Following chemotherapy, radical excision of the epigastric lump with mesh abdominoplasty was carried out. Intraoperatively, there was a 3×3 cm tumor in the anterior abdominal wall at the scar site. There was no evidence of disease in gallbladder fossa, and there were no liver, omental, or peritoneal deposits. Histopathology report showed moderately differentiated adenocarcinoma (Fig. 2); all margins were free of tumor. The tumor cells were immunopositive for cytokeratin (CK) 7 and 19, while negative for CK20. The CK7 and 19 co-positivity indicate that the tumors originate from simple glandular epithelium like hepatobiliary, lung, etc. CK20 negativity excludes tumors of the colon and rectum (Fig. 3). The combination of morphological picture and immunohistochemistry results was strongly suggestive of metastasis from the gallbladder primarily, especially in view of past laparoscopic cholecystectomy, recurrence at port site, and absence of any other site of disease. She was planned for postoperative radiotherapy with 45–50 Gy; however, she reported to have disseminated peritoneal disease and lung metastasis detected on PET-CT after 3 months of surgery. She was advised palliative treatment.
J Gastrointest Canc
Fig. 1 CECT of the abdomen. a, b Mass in the epigastric region. c, d Post cholecystectomy status with no residual disease in the gallbladder fossa and elsewhere
Case 2 A 35-year-old lady presented to us with a lump in the epigastrium at the port-site scar. She had undergone laparoscopic cholecystectomy for gallstone disease 5 years ago at another hospital. She also denied to have been told about the histopathological examination of gallbladder specimen. Abdominal examination revealed a 4 cm×3 cm parietal lump in the epigastric port site. Contrast-enhanced computed tomography (CECT) scan of abdomen showed a parietal nodule which was indenting the liver and stomach, without invading these structures; the rest of the abdominal structures were normal. Histopathological examination of core cut biopsy
Fig. 2 a Microphotograph showing a tumor adjacent to skeletal muscle (H&E, ×40). b The tumor cells arranged in acini (×200)
specimen of the lump confirmed metastatic adenocarcinoma of gallbladder origin. She underwent radical excision of the epigastric lump with mesh abdominoplasty. Intraoperatively, there was a 5×4 cm tumor at the port site; there was no liver, omental, or peritoneal deposit, and the gallbladder fossa was clean. Histopathological examination of the resected specimen revealed metastatic adenocarcinoma in the abdominal wall, involving the muscle and subcutaneous tissue. Morphology was consistent with the primary gallbladder cancer. Though she was advised chemotherapy, she did not agree for it. She is asymptomatic after 3 years of follow-up.
J Gastrointest Canc
Fig. 3 Microphotograph showing that the tumor cells are a immunopositive for cytokeratin (CK) 7 (IHC, ×200), b immunopositive for CK19 (IHC, ×200), and c negative for CK20 (IHC, ×200)
Discussion Gallbladder cancer is often diagnosed incidentally on histopathological examination of the gallbladder specimen following cholecystectomy for a gallstone disease. These patients should undergo revision surgery if the muscularis layer is involved by the tumor (T1b or higher stage) [3, 4]. Recommendations and practices regarding port-site resection vary. While traditionally it has been recommended that all port sites be resected, recent data shows that port-site resection is not associated with improved outcome and should not be considered mandatory [5]. The author’s (DP) practice is to resect the port site through which the gallbladder was retrieved (usually the epigastric port). If this is not known, both epigastric and umbilical port sites are resected. Suspicion of gallbladder cancer during laparoscopic cholecystectomy being done for gallstone disease warrants conversion to open surgery in view of the high risk of port-site metastasis [6]. Patients who develop port-site recurrence following laparoscopic cholecystectomy do so within a short interval. Such patients usually have associated disseminated peritoneal diseases and have poor outcome [7]. A few long-term survivors who were treated for port-site recurrences following laparoscopic cholecystectomy for incidentally detected gallbladder cancer have been reported [8]. Delayed port-site metastasis is rarer; the longest duration between laparoscopic cholecystectomy and appearance of port-site recurrence reported so far in the literature is 4 years [9, 10]. Our patients presented with port-site recurrences after a long duration (more than 5 years) following laparoscopic cholecystectomy. Early recurrences at the port site may be associated more often with aggressive tumor biology and concurrent peritoneal metastases. Late recurrences, on the other hand, may be a manifestation of local tumor implantation at the port site during extraction of the gallbladder. Need of other port-site resection and doing completion radical cholecystectomy in such cases is questionable. In the above cases, resection was not done as recurrence may have been a manifestation of local tumor implantation. It
is recommended that gallbladder specimen should be extracted using a retrieval bag during laparoscopic cholecystectomy; compliance on the part of surgeons is poor due to cost and time factor. Moreover, retrieval bags also do not eliminate the possibility of local tumor cell implantation completely [11]. In conclusion, delayed port-site metastasis usually indicates localized disease and favors long-term survival in gallbladder cancer in contrast to early port-site metastasis which mostly indicates disseminated peritoneal disease. It cannot be overstressed that all the gallbladder specimens must be subjected to histopathological examination following cholecystectomy for gallstone disease.
Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Garg PK, Teckchandani N, Hadke NS, Chander J, Nigam S, Puri SK. Alteration in coagulation profile and incidence of DVT in laparoscopic cholecystectomy. Int J Surg. 2009;7:130–5. 2. Siddiqui FG, Memon AA, Abro AH, Sasoli NA, Ahmad L. Routine histopathology of gallbladder after elective cholecystectomy for gallstones: waste of resources or a justified act? BMC Surg. 2013;13:26. 3. Reid KM, Ramos-De la Medina A, Donohue JH. Diagnosis and surgical management of gallbladder cancer: a review. J gastrointest Surg. 2007;11:671–81. 4. Abramson MA, Pandharipande P, Ruan D, Gold JS, Whang EE. Radical resection for T1b gallbladder cancer: a decision analysis. HPB (Oxford). 2009;11:656–63. 5. Maker AV, Butte JM, Oxenberg J, Kuk D, Gonen M. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol. 2012;19:409–17. 6. Fong Y, Brennan MF, Turnbull A, Colt DG, Blumgart LH. Gallbladder cancer discovered during laparoscopic surgery. Potential for iatrogenic tumor dissemination. Arch Surg. 1993;128: 1054–6. 7. Z’graggen K, Birrer S, Maurer CA, Wehrll H, Klalber C, Baer HU. Incidence of port site recurrence after laparoscopic cholecystectomy
J Gastrointest Canc for preoperatively unsuspected gallbladder carcinoma. Surgery. 1998;124:831–8. 8. Suzuki K, Kimura T, Hashimoto H, Nishihara T, Ogawa H. Port site recurrence of gallbladder cancer after laparoscopic surgery: two case reports of long-term survival. Surg Laparosc Endosc Percutan Tech. 2000;10:86–8. 9. Nakagawa S, Tada T, Furukawa S, Abe M, Hatakeyama K. Late-type recurrence at the port site of unexpected gallbladder carcinoma after a
laparoscopic cholecystectomy: report of a case. Surg Today. 2000;30: 853–5. 10. Jeon HM, Kim JS, Lee CD, Kim EK, Kim SN. Late development of umbilical metastasis after laparoscopic cholecystectomy for gallbladder carcinoma. Oncol Rep. 1999;6:283–7. 11. Paolucci V, Schaeff B, Schneider M, Gutt C. Tumor seeding following laparoscopy: international survey. World J Surg. 1999;23: 989–95.
