Management of Port-Site Metastasis After Laparoscopic Surgery for Ovarian Cancer

Abstract & Commentary

Synopsis: Port-site metastasis after laparoscopic surgery during chemotherapy, or when adequate chemotherapy has been given, is usually associated with poor outcome.

Source: Huang K-G et al. Am J Obstet Gynecol. 2003; 189:16-21.

In an attempt to define the clinical features and long-term prognosis of port-site metastasis after primary laparoscopic surgery for ovarian cancer, Huang and associates reviewed all patients with ovarian cancer who had undergone primary laparoscopic surgery at their institution. They then analyzed the clinicopathologic factors, presentation of port-site implants, management of the individual patient, long-term outcome, and several molecular biomarkers (flow cytometry, p53, p27, bax, HER-2/neu, and bcl-2). Of the 31 patients with epithelial ovarian cancer or borderline malignancy who underwent primary laparoscopic surgery over an 8-year period, 6 (19.4%) had port-site metastasis. Another 2 patients were referred after port-site metastasis. Those patients who had port-site metastasis develop during chemotherapy (n = 2) or after adequate chemotherapy treatment was given (n = 2) all died of cancer. Two patients were alive without disease; the tumors of these latter 2 patients were p27-positive and p53-negative, HER-2/neu-negative, and bcl-2-negative. Huang et al concluded that port-site metastasis after laparoscopic surgery during chemotherapy, or when adequate chemotherapy had been given, is usually associated with poor outcome. They also concluded that further investigations are necessary to define the mechanisms and effective management to prevent and treat this serious complication.

Comment by David M. Gershenson, MD

Minimally invasive surgery has clearly experienced a major resurgence in popularity among gynecologists over the past decade or so. This transformation has principally related to improvements in technology, including optics. Gynecologic oncology has not been immune from this change, and certain groups of oncologists have not only embraced these advances but have rapidly expanded indications for the use of operative laparoscopy. Minimally invasive surgery has been used extensively for surgical staging and restaging for various malignancies, primary surgical treatment of endometrial cancer, radical surgical techniques for cervical cancer, and for pelvic and paraaortic lymphadenectomy. While these procedures have been advocated by some groups for treatment of ovarian cancer, most gynecologic oncologists believe that there is no role for such in this malignancy. One of the major objections for its use in ovarian cancer has been the incidence of port-site metastases, although this complication has been reported in virtually all gynecologic cancers. However, laparoscopy has been used very effectively in the resection of benign adnexal masses; the problem lies in inability to accurately distinguish benign from malignant disease using currently available studies (ultrasound, serum CA 125, etc). The precise mechanism of port-site metastasis remains unclear, but pressure gradients and oxygen content have been implicated in its etiology. The present study simply relates this phenomenon to prognosis in patients treated with postoperative chemotherapy. Several strategies have been suggested to avoid this complication, including using gasless techniques, wound irrigation with saline or heparin, various topical agents, or immediate chemotherapy. The bottom line—laparoscopy should not be used in any patient with known ovarian cancer.

Dr. Gershenson is Professor and Chairman Department of Gynecology M.D. Anderson Cancer Center, Houston.