Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression—a case report

Background Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer. Case presentation A 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later. Conclusion Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Port-Site Metastasis (PSM): Definition, clinical contexts and possible preventive actions to reduce risk

The "port-site metastasis" represents a tumor recurrence that develops in the abdominal wall within the scar tissue of the insertion site of one or more trocars, after laparoscopic surgery, not associated with peritoneal carcinomatosis. This last aspect is central because in the literature some isolated cases are reported, but most cases are associated with peritoneal carcinomatosis. The first case in the literature dates back to 1978 and in the literature, the incidence varies from 1% to 21%, although most published research reports a very small number of patients. Currently, the incidence in a specialized cancer center is consistent with the incidence of recurrence on a laparotomy scar. Possible mechanisms for cell implantation at the port site are direct implantation into the wound during forced, unprotected tissue retrieval or from contaminated instruments during tumor dissection; the effect of gas turbulence in lengthy laparoscopic procedures, and embolization of exfoliated cells during tumor dissection or hematogenous spread. Probably, however, the triggering mechanism is necessarily multifactorial. To date, the only significant prognostic factor in patients diagnosed with port-site metastasis is the interval between laparoscopy and the diagnosis of the port site: in fact, patients who develop the port site within 7 months after surgery have a generally worse prognosis, as well as port-site metastasis are more frequent in advanced cancers and the presence of ascites. To reduce the risk, the following measures are proposed in the literature: 1) Select the patient who does not have a metastatic oncologic condition or friable cancerous masses or lymph node spread or attached external or intracystic vegetations, preferring well-localized, benign or low-malignant or otherwise intact tumors; 2) Use wound protectors and use of protective bags (or endo bag) for tissue retrieval; 3) Peritoneal washing with heparin, to prevent free cell adhesion, or washing with cytocidal solutions. Evaluate the utility of using Povidone-iodine, Taurolidine (which has anti-adhesion activity and decreases proangiogenic factors), and chemotherapy products; 4) Avoid removing pneumoperitoneum with trocars in place; 5) Avoiding direct contact between the solid tumor and the port site; 6) Prefer laparoscopy to laparotomy, if possible; 7) Avoid the use of gas or direct CO2 insufflation, although in literature the point is controversial and deserves more attention and study, as the initial hypothesis that CO2 increased the invasion capacity of tumor cells (in vitro and in vivo) has been refuted several times. Insufflation of hyperthermic CO2 and humidified CO2 leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO2 pneumoperitoneum; 8) Comply with surgical protocols and techniques by updating one's surgical skills, as it has been demonstrated, as already reported here, the presence of cancerous cells on instruments, washing systems and trocars (in particular, on the trocars of the first operator). Suturing all layers of the abdominal wall decreases the risk of the port site; 9) Avoid excessive manipulation of the tumor mass during the surgical/operative procedure.

Axillary Nodal Metastasis of Operated Gallbladder Carcinoma – First Remote Site of Aggression.

Background: Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer.Case summary: A 63-year-old gentleman presented with the complaint of a non-healing ulcer at epigastrium for the last 1 month, after having undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed bilateral axillary metastasis. He then underwent bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later.Conclusion: Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of bilateral axillary lymph nodes as the first distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Analysis of Port Site Complications & Measures to Prevent them

Background: Port site complications following elective laparoscopic surgeries are rare. Port site infection is the most common complication. Objectives: The study was conducted to analyze port site complications occurring in the patients undergoing laparoscopic surgeries and measures to prevent them. Patients and Methods: Total 408 patients who underwent various laparoscopic surgeries were included in the study. Follow up was done for 3 months postoperatively. Port site was examined for any complication. Result: Out of 408 patients 24 patients (5.88%) developed port site complications. 14 patients developed post site infection, 4 patients had port site discharge with sinus formation, 4 patients developed port site bleeding and 2 patients had port site hernia. No case of port site metastasis or visceral injury while port insertion were found. No patient had port site omental entrapment. Conclusion: Minimally invasive surgery is a safe and effective with minimal complication.

Ovarian Cancer as Random Finding in Laparoscopy

Laparoscopy can be used for almost all gynecological procedures and is considered as the indicated method for specific procedures. This is especially true for adnexal surgery. Of course, while it is considered a method of choice for the treatment of benign ovarian tumors, the same does not apply to malignant ones, although treatment of ovarian cancer either at an early or even at a more advanced stage is feasible with laparoscopy. Finding malignancy, when not suspected, during laparoscopic treatment of an ovarian cyst is a situation raising several issues, depending on whether the identification of malignancy is intra- or post-operative, which involve inadequate surgical staging, peritoneal spread of cancer cells, intraoperative rupture of a malignant ovarian cystic tumor, and port site metastasis. This chapter analyzes the possible adverse events related to the use of laparoscopy in the treatment of adnexal masses considered as benign but turn out to be malignant, and how they can be mitigated with careful preoperative patient selection and with adequate surgical experience.