- Email: [email protected]
Abdominal wall metastases from ovarian cancer after laparoscopy
Abdominal wall metastases from ovarian cancer after laparoscopy Noreen C. Gleeson, MD," Santo V. Nicosia, MD, MS,b James E. Mark, MD," Mitchel S. Hoffman, MD," and Denis Cavanagh, MD" Tampa, Florida We report three cases of abdominal wall metastases from ovarian cancer after laparoscopy. The implants occurred at the site of insertion of laparoscopy trocars. One patient had an implant of serous papillary carcinoma of low malignant potential at the trocar sites after Japaroscopic oophorectomy. Laparoscopic surgery is inappropriate in patients with malignant ascites or when preoperative or intraoperative findings are suggestive of ovarian cancer. (AM J OBSTET GVNECOL 1993;169:522-3.)
Key words: Laparoscopy, ovarian cancer, abdominal wall metastasis
The gynecologic applications of laparoscopy have been extended to include selective cancers, and some authorities even recommend it in the management of stage I borderline cancers of the ovary. 1
Case reports A 31-year old nulliparous white woman had a 4 cm left adnexal mass noted on routine gynecologic examination, and it was confirmed to be a unilocular ovarian cyst by ultrasonography. This cyst persisted over a 5-week period. In spite of the laparoscopic finding of papillary excrescences on both ovaries, a left salpingooophorectomy and right ovarian biopsy were performed laparoscopically. The ovarian tissue was extracted from the abdominal cavity through the second laparoscopic sleeve in the left lower quadrant. The tumor was serous papillary tumor of low malignant potential (borderline) in both ovaries. At staging laparotomy 2 weeks later we found a 2 cm subcutaneous nodule in the left lower quadrant of the abdomen and tumor deposits on the pelvic peritoneum. All visible tumor was removed. Histopathologic examination confirmed the prior diagnosis with deposits on the peritoneum and in the subcutaneous tissue of the abdominal wall. The patient is currently being treated with cisplatin and cyclophosphamide. Two patients, aged 69 and 79 years, were referred to our service after laparoscopy, which was performed in the presence of clinically and ultrasonographically detected ascites. Ascites had been drained, and samples of From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Florida, a and the Department of Pathology, H. Lee Moffitt Cancer Center and Tampa General Hospital.' Received for publication February 5, 1993; revised March 5, 1993; accepted April 15, 1993. Reprint requests: Noreen C. Gleeson, Harbourside Medical Tower, Suite 547, 4 Columbia Dr., Tampa, FL 33606. Copyright © 1993 by Mosby-Year Book, Inc. 0002-9378193 $1.00 + .20 6/1/48004
522
pelvic carcinomatosis were removed for biopsy in each case. Histopathologic examination revealed poorly differentiated ovarian carcinoma and serous papillary carcinoma. Both patients were referred to our service within 2 weeks of laparoscopy, and palpable subcutaneous masses up to 8 cm in diameter had developed at one or two of the laparoscopic trocar sites by that time. Staging laparotomy with optimal debulking « 2 cm residual) was performed. Removal of the abdominal wall masses necessitated excision of the umbilicus and repair of the rectus sheath defect with a synthetic mesh in one case. Both patients were commenced on cyclic carboplatin and cyclophosphamide chemotherapy.
Comment Laparoscopic operative management of ovarian cysts inevitably results in the removal of adnexal masses that are subsequently found to be malignant, because gross malignant features are not always present. 2 In the first case presented, laparoscopic assessment of a 4 cm unilocular ovarian cyst was appropriate, but laparoscopic removal of ovarian tissue in the presence of bilateral surface excrescences, a feature highly suspicious for the presence of malignancy, resulted in seeding of the abdominal wall with tumor. Although this was a tumor of low malignant potential otherwise confined to the pelvis, the rapid growth of the abdominal wall drop metastasis in this case suggested that this was a biologically aggressive tumor, and we felt obligated to offer adjuvant chemotherapy to this patient. Although there are some reports of abdominal wall seeding after laparoscopic biopsy, to our knowledge ours is the first case report of abdominal wall seeding after laparoscopic oophorectomy in the presence of a serous ovarian tumor of low malignant potential. Displacement of ovarian tumor to sites outside the peritoneal cavity may remove it from restraining factors present in its natural
Belfort and Saade
Volume 169, Number 3 Am J Obstet Gynecol
intraperitoneal environment and account for the very rapid growth seen in these metastases. Because paracentesis carries a risk of abdominal wall tumor seeding, aspiration of malignant ascites is generally avoided before staging laparotomy in ovarian cancer. Cutaneous tumor nodules can occur in laparotomy scars, but careful irrigation of the wound after closure of the rectus sheath probably minimizes this risk. In the second and third cases presented the patients' chemotherapeutic management was not altered by the presence of tumor nodules, but the presence of tumor in the abdominal wall may affect their prognosis. In addition, one patient is left at a cosmetic disadvantage from removal of the umbilicus. These patients may be at risk for abdominal wall tumor recurrence, which is a distressing condition because of its overt nature. The contraindications to laparoscopic surgery are
well established, and these cases are principally indictments of poor surgical judgment. In the current wave of enthusiasm for operative laparoscopy in gynecologic malignancies, they serve as a reminder that laparoscopy is contraindicated when ovarian cancer is present or suspected. We disagree with the suggestion of Reich et a1. 1 that laparoscopic staging is appropriate in borderline ovarian tumors. The role of operative laparoscopy in the management of adnexal masses and perhaps selected early ovarian cancers continues to evolve, but it should proceed with extreme caution. REFERENCES 1. Reich H, McGlynn F, Wilkie W. Laparoscopic management
of stage 1 ovarian cancer. J Reprod Med 1990;35:601-4. 2. Maiman M, Seltzer V, Boyce J. Laparoscopic excision of ovarian neoplasms subsequently found to be malignant. Obstet Gynecol 1991;77:563-5.
Retinal vasospasm associated with visual disturbance in preeclampsia: Color flow Doppler findings Michael A. Belfort, MD, and George R. Saade, MD Houston, Texas This case report demonstrates retinal vasospasm during a period of visual disturbance in a patient with preeclampsia. Doppler assessment of the orbital vasculature was performed during and after the episode. Central retinal artery blood velocity increased, and resistance decreased, after resolution of symptoms. Visual disturbances in preeclampsia may be associated with retinal artery vasospasm and ischemia. (AM J OBSTET GVNECOL 1993;169:523-5.)
Key words: Central retinal artery, Doppler
Visual disturbances, particularly flashes of light, have frequently been reported in patients with preeclampsiaeclampsia. The cause of this symptom is unknown, but because preeclampsia is associated with severe retinal vasospasm, 1 it is likely that ischemia plays a role. However, there are no published data acquired from a patient during an episode of visual disturbance to
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine. Received for publication March 2, 1993; revised April 20, 1993; accepted May 6, 1993. Reprint requests: Michael A. Belfort, MD, Division ofMaternal-Fetal Medicine, Department of Obstetrics and Gynecology, One Baylor Flaw, Houstin, TX 77030. Copyright © 1993 by Mosby-Year Book, 1nc. 0002-9378/93 $1.00 + .20 6/1/48451
support this theory. We report a case in which the orbital arterial supply was assessed with color flow Doppler ultrasonography during and after an episode of visual disturbance in a patient with imminent eclampsia.
Case report A 28-year-old Hispanic woman, gravida 3, para 2, was admitted to the Ben Taub Hospital at 36 weeks' gestation with a blood pressure of 181/93 mm Hg and proteinuria (2 + ). There was no history of chronic renal disease or chronic hypertension, and her prenatal course had been otherwise uneventful. A diagnosis of preeclampsia was made. The patient complained of a severe headache on admission and soon afterward reported visual disturbances characterized by flashes of bright light in both eyes. Color flow Doppler examina-
523
Key words: Laparoscopy, ovarian cancer, abdominal wall metastasis
The gynecologic applications of laparoscopy have been extended to include selective cancers, and some authorities even recommend it in the management of stage I borderline cancers of the ovary. 1
Case reports A 31-year old nulliparous white woman had a 4 cm left adnexal mass noted on routine gynecologic examination, and it was confirmed to be a unilocular ovarian cyst by ultrasonography. This cyst persisted over a 5-week period. In spite of the laparoscopic finding of papillary excrescences on both ovaries, a left salpingooophorectomy and right ovarian biopsy were performed laparoscopically. The ovarian tissue was extracted from the abdominal cavity through the second laparoscopic sleeve in the left lower quadrant. The tumor was serous papillary tumor of low malignant potential (borderline) in both ovaries. At staging laparotomy 2 weeks later we found a 2 cm subcutaneous nodule in the left lower quadrant of the abdomen and tumor deposits on the pelvic peritoneum. All visible tumor was removed. Histopathologic examination confirmed the prior diagnosis with deposits on the peritoneum and in the subcutaneous tissue of the abdominal wall. The patient is currently being treated with cisplatin and cyclophosphamide. Two patients, aged 69 and 79 years, were referred to our service after laparoscopy, which was performed in the presence of clinically and ultrasonographically detected ascites. Ascites had been drained, and samples of From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Florida, a and the Department of Pathology, H. Lee Moffitt Cancer Center and Tampa General Hospital.' Received for publication February 5, 1993; revised March 5, 1993; accepted April 15, 1993. Reprint requests: Noreen C. Gleeson, Harbourside Medical Tower, Suite 547, 4 Columbia Dr., Tampa, FL 33606. Copyright © 1993 by Mosby-Year Book, Inc. 0002-9378193 $1.00 + .20 6/1/48004
522
pelvic carcinomatosis were removed for biopsy in each case. Histopathologic examination revealed poorly differentiated ovarian carcinoma and serous papillary carcinoma. Both patients were referred to our service within 2 weeks of laparoscopy, and palpable subcutaneous masses up to 8 cm in diameter had developed at one or two of the laparoscopic trocar sites by that time. Staging laparotomy with optimal debulking « 2 cm residual) was performed. Removal of the abdominal wall masses necessitated excision of the umbilicus and repair of the rectus sheath defect with a synthetic mesh in one case. Both patients were commenced on cyclic carboplatin and cyclophosphamide chemotherapy.
Comment Laparoscopic operative management of ovarian cysts inevitably results in the removal of adnexal masses that are subsequently found to be malignant, because gross malignant features are not always present. 2 In the first case presented, laparoscopic assessment of a 4 cm unilocular ovarian cyst was appropriate, but laparoscopic removal of ovarian tissue in the presence of bilateral surface excrescences, a feature highly suspicious for the presence of malignancy, resulted in seeding of the abdominal wall with tumor. Although this was a tumor of low malignant potential otherwise confined to the pelvis, the rapid growth of the abdominal wall drop metastasis in this case suggested that this was a biologically aggressive tumor, and we felt obligated to offer adjuvant chemotherapy to this patient. Although there are some reports of abdominal wall seeding after laparoscopic biopsy, to our knowledge ours is the first case report of abdominal wall seeding after laparoscopic oophorectomy in the presence of a serous ovarian tumor of low malignant potential. Displacement of ovarian tumor to sites outside the peritoneal cavity may remove it from restraining factors present in its natural
Belfort and Saade
Volume 169, Number 3 Am J Obstet Gynecol
intraperitoneal environment and account for the very rapid growth seen in these metastases. Because paracentesis carries a risk of abdominal wall tumor seeding, aspiration of malignant ascites is generally avoided before staging laparotomy in ovarian cancer. Cutaneous tumor nodules can occur in laparotomy scars, but careful irrigation of the wound after closure of the rectus sheath probably minimizes this risk. In the second and third cases presented the patients' chemotherapeutic management was not altered by the presence of tumor nodules, but the presence of tumor in the abdominal wall may affect their prognosis. In addition, one patient is left at a cosmetic disadvantage from removal of the umbilicus. These patients may be at risk for abdominal wall tumor recurrence, which is a distressing condition because of its overt nature. The contraindications to laparoscopic surgery are
well established, and these cases are principally indictments of poor surgical judgment. In the current wave of enthusiasm for operative laparoscopy in gynecologic malignancies, they serve as a reminder that laparoscopy is contraindicated when ovarian cancer is present or suspected. We disagree with the suggestion of Reich et a1. 1 that laparoscopic staging is appropriate in borderline ovarian tumors. The role of operative laparoscopy in the management of adnexal masses and perhaps selected early ovarian cancers continues to evolve, but it should proceed with extreme caution. REFERENCES 1. Reich H, McGlynn F, Wilkie W. Laparoscopic management
of stage 1 ovarian cancer. J Reprod Med 1990;35:601-4. 2. Maiman M, Seltzer V, Boyce J. Laparoscopic excision of ovarian neoplasms subsequently found to be malignant. Obstet Gynecol 1991;77:563-5.
Retinal vasospasm associated with visual disturbance in preeclampsia: Color flow Doppler findings Michael A. Belfort, MD, and George R. Saade, MD Houston, Texas This case report demonstrates retinal vasospasm during a period of visual disturbance in a patient with preeclampsia. Doppler assessment of the orbital vasculature was performed during and after the episode. Central retinal artery blood velocity increased, and resistance decreased, after resolution of symptoms. Visual disturbances in preeclampsia may be associated with retinal artery vasospasm and ischemia. (AM J OBSTET GVNECOL 1993;169:523-5.)
Key words: Central retinal artery, Doppler
Visual disturbances, particularly flashes of light, have frequently been reported in patients with preeclampsiaeclampsia. The cause of this symptom is unknown, but because preeclampsia is associated with severe retinal vasospasm, 1 it is likely that ischemia plays a role. However, there are no published data acquired from a patient during an episode of visual disturbance to
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine. Received for publication March 2, 1993; revised April 20, 1993; accepted May 6, 1993. Reprint requests: Michael A. Belfort, MD, Division ofMaternal-Fetal Medicine, Department of Obstetrics and Gynecology, One Baylor Flaw, Houstin, TX 77030. Copyright © 1993 by Mosby-Year Book, 1nc. 0002-9378/93 $1.00 + .20 6/1/48451
support this theory. We report a case in which the orbital arterial supply was assessed with color flow Doppler ultrasonography during and after an episode of visual disturbance in a patient with imminent eclampsia.
Case report A 28-year-old Hispanic woman, gravida 3, para 2, was admitted to the Ben Taub Hospital at 36 weeks' gestation with a blood pressure of 181/93 mm Hg and proteinuria (2 + ). There was no history of chronic renal disease or chronic hypertension, and her prenatal course had been otherwise uneventful. A diagnosis of preeclampsia was made. The patient complained of a severe headache on admission and soon afterward reported visual disturbances characterized by flashes of bright light in both eyes. Color flow Doppler examina-
523