Port-site metastasis nei tumori ginecologicitumori ginecologici

Stefano PalombaStefano Palomba

Unità Operativa Complessa di Ginecologia ed OstetriciaIRCSS, Azienda Ospedaliera ASMNUniversità di Modena e Reggio Emilia

Reggio Emilia

“trocar-site metastasis” or “port-site metastasis”

…A case of a developing local metastasis at the place of

An historical viewAn historical view

…A case of a developing local metastasis at the place of the penetration of the pneu-needle and of the trocar in the second week after diagnostic laparoscopy for a case of ovarian cancer with the mediation of ascites-

containing malignant cells…DobronteDobronte etet al., al., EndoscopyEndoscopy 19781978

Strict definitionStrict definition“..early tumor recurrences that develop locally “..early tumor recurrences that develop locally in the abdominal wall, within the scar tissue of in the abdominal wall, within the scar tissue of one or more one or more trocartrocar sites or an sites or an incisionalincisional wound wound after laparoscopy and these should not be after laparoscopy and these should not be associated with peritoneal associated with peritoneal carcinosiscarcinosis…”…”

DefinitionDefinition

associated with peritoneal associated with peritoneal carcinosiscarcinosis…”…”ReymondReymond et al., J et al., J GatrointestinalGatrointestinal SurgSurg 19981998

Wide definitionWide definitioncancer recurrence in the scar tissue at cancer recurrence in the scar tissue at one or more one or more trocartrocar sites or at the sites or at the incision wound after laparoscopyincision wound after laparoscopy

In highIn high--risk patient risk patient ??

Local manifestations of disseminated disease Local manifestations of disseminated disease ??

Unsolved questionsUnsolved questions

Local manifestations of disseminated disease Local manifestations of disseminated disease ??

Appropriate Appropriate periperi--operative treatment ?operative treatment ?

Clinical impact of portClinical impact of port--site metastasissite metastasis

Endometrial cancerEndometrial cancer

Cervical cancerCervical cancer

Golden standard surgeryGolden standard surgery

IncidenceIncidence

Ovarian cancerOvarian cancer

Feasibility stateFeasibility state

Diagnostic laparoscopy for Diagnostic laparoscopy for advanced ovarian canceradvanced ovarian cancer

IncidenceIncidence00--20%20%

Rate of portRate of port--site metastasissite metastasis

ZivanovicZivanovic etet al., al., GynecolGynecol OncolOncol 20082008

Rate of portRate of port--site metastasissite metastasis

MartìnezMartìnez etet al., al., GynecolGynecol OncolOncol 20102010

EtiologyEtiology

HematogenousHematogenous spread spread ((neoplasticneoplastic emboli)emboli)

Direct contamination/implantation Direct contamination/implantation (by instrument and tissue contamination)(by instrument and tissue contamination)

Effects of Effects of pneumoperitoneumpneumoperitoneumEffects of Effects of pneumoperitoneumpneumoperitoneum(pressures, (pressures, aerosolizationaerosolization, “chimney effect”, CO2) , “chimney effect”, CO2)

Local immune reactionLocal immune reaction

Surgical techniqueSurgical technique

(peritoneum opened, (peritoneum opened, trocartrocar nonnon--fixated, use of Harmonic scalpel, …)fixated, use of Harmonic scalpel, …)

Prevention strategiesPrevention strategies•• Patients’ selectionPatients’ selection

•• Use wound protectorsUse wound protectors

•• Minimal tumor dissemination Minimal tumor dissemination (minimal manipulation and (minimal manipulation and endobagsendobags use)use)

•• Rinse Rinse trocarstrocars and tip of instrument in 5% and tip of instrument in 5% povidinepovidine--iodine before insertioniodine before insertion

•• Avoid carbon dioxide leaks Avoid carbon dioxide leaks (anchor ports to prevent dislodgment, avoid sudden (anchor ports to prevent dislodgment, avoid sudden desufflationsdesufflations, and deflate the abdomen with , and deflate the abdomen with trocartrocar in place)in place)

•• Irrigate instruments and ports before and after Irrigate instruments and ports before and after trocartrocar removalremoval

•• Irrigate and suction abdomenIrrigate and suction abdomen•• Irrigate and suction abdomenIrrigate and suction abdomen

•• Use heparin or Use heparin or povidonepovidone--iodine solution to irrigate wound and abdomeniodine solution to irrigate wound and abdomen

•• Closure of all abdominal layers including peritoneumClosure of all abdominal layers including peritoneum

•• Excision of Excision of trocartrocar sites (for advanced ovarian cancer)sites (for advanced ovarian cancer)

•• Postoperative portPostoperative port--site radiationsite radiation

•• Early definitive surgery or chemotherapyEarly definitive surgery or chemotherapy

•• Use of local 5Use of local 5--fluoruracile or fluoruracile or taurolidinetaurolidine

•• IntraperitonealIntraperitoneal endotoxinendotoxin

RamirezRamirez etet al., al., GynecolGynecol OncolOncol 20032003

PortPort--site metastases of endometrial cancersite metastases of endometrial cancerA systematic reviewA systematic review

Palomba Palomba etet al., J al., J MinimMinim Invasive Invasive GynecolGynecol 20122012

PortPort--site metastases of endometrial cancersite metastases of endometrial cancerA systematic reviewA systematic review

Palomba Palomba etet al., J al., J MinimMinim Invasive Invasive GynecolGynecol 20122012

PortPort--site metastases of endometrial cancersite metastases of endometrial cancerA systematic reviewA systematic review

Palomba Palomba etet al., J al., J MinimMinim Invasive Invasive GynecolGynecol 20122012

PortPort--site metastases of endometrial cancersite metastases of endometrial cancerA systematic reviewA systematic review

• No relationship with grade, histotype and patients’ characteristics.

• High mortality (both non-isolated and isolated recurrences).

Non-univocal treatment.

Palomba Palomba etet al., J al., J MinimMinim Invasive Invasive GynecolGynecol 20122012

• Non-univocal treatment.

IncisionalIncisional metastases of endometrial cancermetastases of endometrial cancerLiterature dataLiterature data

MaciasMacias (2003)(2003)

PortPort--site metastases of cervical cancersite metastases of cervical cancer

The first case The first case ofof umbilicalumbilical metastasismetastasis afterafterlaparoscopiclaparoscopic retroperitonealretroperitoneal paraaorticparaaorticlymphadenectomy lymphadenectomy forfor cervicalcervical cancercancer

MartìnezMartìnez--PalonesPalones etet al., J al., J MinimMinim Invasive Invasive GynecolGynecol 20052005

PortPort--site metastases of cervical cancersite metastases of cervical cancer

MartìnezMartìnez etet al., al., GynecolGynecol OncolOncol 20102010

PortPort--site metastases of ovarian cancersite metastases of ovarian cancer

••The risk is highest in patients with recurrence of The risk is highest in patients with recurrence of ovarian or primary peritoneal malignancies undergoing ovarian or primary peritoneal malignancies undergoing

procedures in the presence of procedures in the presence of ascitesascites..NagarshethNagarsheth etet al., JSLS 2004al., JSLS 2004

VergoteVergote etet al., al., IntInt J J CancerCancer 20052005

• ~ 20 % of patients with ovarian cancers treated with surgical endoscopy develops port-site metastasis•Stage, histology, and interval of subsequent treatment are not associated with their incidence• More than half of cases, the port-site metastasis is detected within 4 weeks after laparoscopy• Port-site metastasis development during or after chemotherapy is a strong predictive factor for survival

Huang Huang etet al., Am J al., Am J ObstetObstet GynecolGynecol 20032003

PortPort--site metastases of ovarian cancersite metastases of ovarian cancer

In borderline tumors the rate of port-site metastasis is ~0%

Huang Huang etet al., Am J al., Am J ObstetObstet GynecolGynecol 20032003

MoriceMorice etet al., al., ObstetObstet GynecolGynecol 20042004

Three cases of port-sites implantation after laparoscopic treatment of borderline ovarian tumors.

The surgical resection is resolutive.

Tailoring for the prevention and the Tailoring for the prevention and the treatment of porttreatment of port--site metastasessite metastases

Predictors for portPredictors for port--site site metastasis occurrencemetastasis occurrence

Predictors for survival in Predictors for survival in patients with portpatients with port--site site

metastasismetastasis

Predictors for development of portPredictors for development of port--site site metastasesmetastases

Any clinical predictor!

Huang Huang etet al., Am J al., Am J ObstetObstet GynecolGynecol 20032003

Predictors for survival in patients Predictors for survival in patients with portwith port--site metastasissite metastasis

ZivanovicZivanovic etet al., al., GynecolGynecol OncolOncol 20082008

TakeTake--home messagehome message

• No relationship with grade, histotype and patients’ characteristics in order to use all preventive (and aggressive) strategies.

• Use indiscriminate of low abdominal pressures (12-14 mmHg), peritoneal closure (for 10-12mm ports), and irrigation of trocars and accesses with povidone-iodine solution.of trocars and accesses with povidone-iodine solution.

• The carcinosis should be always excluded.

• Non-univocal specific treatment.

• Aggressive treatment for isolated recurrences of endometrial (excision plus radiotherapy) and ovarian cancer (chemotherapy with or without excision).

• Local treatment port-site metastasis of cervical cancer.