|Year : 2021 | Volume
| Issue : 3 | Page : 128-133
Tumor recurrence in a previous abdominal incision site in a patient with endometrial adenocarcinoma: A case report
Patricia Marie T. Fernandez, Jericho Thaddeus P. Luna
Department of Obstetrics and Gynecology, Philippine General Hospital, University of the Philippines, Manila, Philippines
|Date of Submission||15-Jul-2021|
|Date of Acceptance||15-Jul-2021|
|Date of Web Publication||4-Sep-2021|
Patricia Marie T. Fernandez
Department of Obstetrics and Gynecology, Philippine General Hospital, Taft Avenue, Ermita, Manila - 1000
Source of Support: None, Conflict of Interest: None
Endometrial cancer is frequently diagnosed at an early stage and exhibits a good prognosis. However, 10%–15% of tumors recur usually within 3 years. Common sites of recurrence are the vaginal vault and pelvis. Only a number of case reports exist for tumor recurrence in a previous incision site. We present a case of a 71-year-old Filipino woman, a diagnosed case of Endometrial Adenocarcinoma Stage III A, FIGO Grade 1, who underwent surgical management, chemotherapy, and radiation therapy 9 years prior, presenting with an abdominal mass at the inferior aspect of the previous surgical scar with the foul-smelling discharge of 1-year duration. Physical examination revealed a 6 cm × 4 cm, friable, movable, nontender abdominal mass, with associated edema of the mons pubis. Surgical resection showed that the mass was confined to the abdominal wall, with no extension beneath the fascia and no evidence of tumor in the pelvic and abdominal cavity. Histological examination revealed a moderately differentiated adenocarcinoma in the abdominal wall, confirming tumor recurrence in an atypical location, probably arising from the previous incision site.
Keywords: Abdominal incision site, endometrial cancer, recurrence
|How to cite this article:|
Fernandez PM, Luna JT. Tumor recurrence in a previous abdominal incision site in a patient with endometrial adenocarcinoma: A case report. Philipp J Obstet Gynecol 2021;45:128-33
|How to cite this URL:|
Fernandez PM, Luna JT. Tumor recurrence in a previous abdominal incision site in a patient with endometrial adenocarcinoma: A case report. Philipp J Obstet Gynecol [serial online] 2021 [cited 2021 Oct 18];45:128-33. Available from: http://www.pjog.org/text.asp?2021/45/3/128/325582
| Introduction|| |
Majority of patients with endometrial cancer are diagnosed at an early stage, hence harbor a favorable prognosis. These patients are managed with primary surgery and adjuvant radiotherapy. There is a recurrence rate of 10%–15% occurring within 3 years, with vaginal vault and pelvis as the common sites. Distant sites such as distant lymph nodes, peritoneum, and visceral organs are relatively rare. Another rare recurrence site is the abdominal incision site. Only a few case reports have been published, therefore no standard of care has been established. We present to you a case of a 71-year-old Filipino woman with Stage IIIA endometrial adenocarcinoma who developed abdominal incision site recurrence 9 years after primary treatment.
| Case Report|| |
A 71-year-old Filipino woman, Gravida 3 Para 3 (3-0-0-3), a diagnosed case of Endometrial Adenocarcinoma Stage III A (with involvement of the fallopian tube) Grade 1 with no lymphovascular invasion, was admitted for a gradually enlarging abdominal mass at the inferior aspect with the previous midline incision site with the foul-smelling discharge of 1-year duration and no other associated symptoms. Nine years before admission, the patient underwent exploratory laparotomy, total hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic node dissection. She had vaginal vault tumor recurrence 1 year later, for which she underwent chemotherapy with cisplatin, and pelvic cobalt, and brachytherapy. The patient was then lost to follow-up. Medical history shows the patient is a known hypertensive for 3 years with good compliance to medication. The patient previously underwent right mastectomy for an enlarged benign breast cyst. She has nephrolithiasis which presented with recurrent urinary tract infection, and has allergy to an unrecalled antibiotic. She is a Gravida 3 Para 3 (3003), with all her pregnancies carried to term and delivered vaginally with no fetomaternal complications. She had her menopause at 58 years old.
On physical examination, the patient had a 6 cm × 4 cm, friable, movable, nontender suprapubic mass with foul-smelling discharge, with associated edema of the mons pubis. The rest of the general physical findings were unremarkable. On internal examination, she had normal external genitalia, intact and smooth vaginal wall with the intact stump, no adnexal masses, or tenderness at the pelvic cavity. On rectovaginal examination, she had good sphincter tone, smooth rectovaginal septum, no intraluminal masses, and no blood per examining finger.
Workup was done which included an abdominal mass biopsy that revealed adenocarcinoma. Laboratory examinations including complete blood count, blood chemistry, and coagulation studies [Table 1] were done and were essentially within normal range except for an elevated Creatinine (88.40 umol/L), impaired fasting glucose (105 mg/dL). The patient also had an elevated CA 125 (509.4U/mL). The electrocardiogram showed sinus rhythm with nonspecific ST-T wave changes [Figure 1]. Imaging studies were done as part of the investigation [Table 2]. Abdominal computed tomography (CT) scan with triple contrast showed a 7.8. cm × 7.5 cm × 7.9 cm solid heterogeneous mass in the hypogastric area involving the rectus abdominis, extending up to the subcutaneous fat, with speculated borders. It also showed a hepatic nodule in segment 2/3 of the liver measuring 2.6 × 1.4 × 1.1, which cannot entirely rule out metastasis. Other workup was done including a holoabdominal ultrasound which revealed a liver with hepatic nodule in segment 2/3, normal gallbladder, kidneys, pancreas, and spleen. It also showed a heterogeneous, predominantly solid, lobulated mass in the pelvic region which appears to arise from the subcutaneous portion of the abdominal wall. The contrast-enhanced chest CT scan revealed no nodules, masses, or abnormal calcifications in the lungs. Bone scintigraphy showed no evidence of metastatic bone disease. Chest X-ray results were noncontributory.
|Figure 1:Specimen obtained showing an irregular abdominal wall mass measuring 14.0 x 9.0 x 6.0 cm (a) anterior view of the abdominal wall mass, with 7.0 x 4.0 cm fluctuant mass that extended to the skin with mucopurulent foul-smelling discharge (b) Cut section of the specimen showing hemorrhagic, necrotic areas foul smelling tissue within (c-d) Coronal and posterior view of the excised abdominal wall mass|
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After evaluation, the patient was admitted for surgical management. She underwent wide local excision of the abdominal wall mass, palpation of the pelvic cavity, and Jackson Pratt insertion under spinal anesthesia. A 2-cm margin around the tumor was attempted but was not possible due to dense adhesions and high vascularity of tumor amounting to significant blood loss. Intraoperative findings showed the mass was confined to the abdominal wall, with no extension beneath the fascia. The bladder dome was grossly free of tumor, and there was no palpable tumor on the lower intraabdominal cavity. The specimen obtained was an irregular mass measuring 14.0 cm × 9.0 cm × 6.0 cm [Figure 1] and on the cut section, it contained hemorrhagic, necrotic areas foul smelling tissue within [Figure 1]b. It also contained a 7.0 cm × 4.0 cm fluctuant mass that extended to the skin with mucopurulent foul-smelling discharge [Figure 1]b. The histopathologic report showed adenocarcinoma, moderately differentiated, which was similar to the primary malignancy [Figure 2].
|Figure 2: Adenocarcinoma, moderately differentiated, with less than 0.1 cm away from the basal margin.(a) Scanning magnification (40x). Back to back endometrial-type glands with atypia with no intervening stroma (b) Low power magnification (100x): Tumor shows back-to-back cribriform arrangement, with areas of necrosis; there are also some areas showing a solid architecture (c) High power magnification (400x). The tumor cells show moderate pleomorphism and prominent nucleoli; there are also atypical mitotic figures seen.|
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The wide excision did not necessitate referral to the Plastic surgery service since the patient has a relatively loose abdomen. The defect was closed without difficulty. The procedure lasted a few hours, with an estimated blood loss of 1.2 liters for which necessitated blood transfusion of 2 units packed RBC. The patient tolerated the procedure well. The patient's postoperative course was unremarkable until the first postoperative day when she started having visual hallucinations, visual illusions, tactile hallucinations and persecutory delirium. She did not have a change in sensorium, disorientation, insomnia, change in appetite, or depressive symptoms. She was then referred to the Psychiatry service. On evaluation, she was noted to have a medication-induced psychotic disorder probably secondary to postanesthesia effect. Risperidone 1 mg/tab once a day was initiated along with psychotherapy and psychoeducation. On the second postoperative day, wound inspection revealed a dry and well-coaptated surgical wound with no associated discharge. In the interim, there was no recurrence of the psychiatric symptoms and the patient was cleared for discharge by the Psychiatry service. The Jackson Pratt drain output was more than 100cc/day, but decreased gradually and was removed before discharge.
One month postoperatively, the patient was readmitted for surgical site infection. A transabdominal ultrasound [Table 3] showed a 5.8 cm × 11.1 cm × 2.8 cm (volume 94.3 ml) low-level echo fluid collection at the anterior abdominal wall, subcutaneous layer (suprapubic area), with intact fascia [Figure 3]. This was followed by an ultrasound-guided aspiration, where 130cc of purulent fluid was aspirated, and pigtail catheter insertion [Figure 4]. Culture studies of the wound abscess showed only active inflammatory disease. There was no note of microbial growth. The patient was given intravenous and antibiotics and was sent home improved. On follow-up, the surgical wound was intact with slight erythema on the lateral portion. The pigtail was intact, with no associated edema.
|Figure 3: Cut section of the specimen showing hemorrhagic, necrotic areas foul smelling tissue within|
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The patient was advised postoperative chemotherapy, but she did not give consent. She went home and opted for symptomatic management.
| Case Discussion|| |
Endometrial cancer is the most common malignancy of the female genital tract in developed countries, with 63,230 estimated new cases and 11,350 estimated deaths in 2018. It has a favorable prognosis in most patients since this is usually diagnosed at an early stage. However, 10%–15% of these patients would have a recurrence within 3 years from primary treatment, with vaginal vault and pelvis as the common sites.
Cutaneous involvement from endometrial cancer is rare, with an incidence rate of <0.8%. Published case reports noted the occurrence of cutaneous involvement at the abdominal incision site such as in our patient and radiotherapy site, and they emphasized the rarity of this form of recurrence. Cutaneous involvement from endometrial cancer may have variable presentation – as discrete nodules, inflammatory lesions, tumors, or plaques. Our patient presented with a tumor that was confined to the subcutaneous tissue and presented as a movable, nontender mass that was discovered to be highly vascular intraoperatively. This is consistent with the description of cutaneous involvement from endometrial cancer based on the case report and literature review by Zahra et al.
For our patient, a tumor recurrence is considered rather than a new primary malignancy because of the initial Stage IIIA of endometrial cancer and the lack of appropriate adjuvant chemotherapy. Based on our local guidelines, the recommended chemotherapeutic regimen are as follows: Carboplatin-Paclitaxel regimen, TAP (Doxorubicin, Cisplatin, Paclitaxel) regimen, AP (Doxorubin-Cisplatin) regimen, Cisplatin-Paclitaxel regimen with radiotherapy, Carboplatin with Pegylated Liposomal Doxorubicin, and Dose-dense TC (Paclitaxel and Carboplatin). Our patient only received cisplatin with pelvic cobalt and brachytherapy.
To our knowledge, only twelve cases of abdominal incision site recurrence of endometrial cancer have been reported, with the last being reported in 2014.,,,,,,,,,,, The pathogenesis of abdominal incision site recurrence of endometrial adenocarcinoma is poorly understood. Patients with positive peritoneal fluid cytology have a higher incidence of recurrence and provide a mechanism for tumor seeding at the time of primary surgery, as reported by Curtis et al. A previous fractional dilatation and curettage create an increased intraperitoneal pressure leading to intraperitoneal tumor seeding. In our case, the peritoneal fluid cytology was negative for malignancy during the time of primary surgery, and the patient did not undergo preoperative dilatation and curettage. The patient was also negative for lymphovascular invasion. Despite this, the patient still had tumor recurrence in the abdominal incision site. The tumor seeding to the abdominal incision site in our patient may have resulted from the fallopian tube involvement based on histopathology after total hysterectomy with bilateral salpingo-oophorectomy. According to Macias et al., malignant cells may also spread intraperitoneally when they penetrate the full thickness of the uterine or the fallopian tube. Another proposed mechanism reported is the spilling of malignant cells through the cervix at the time of hysterectomy with direct implantation on the abdominal incision site. Our patient underwent exploratory laparotomy, total hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic node dissection, with no tumor manipulation. She then had a long disease-free interval of 9 years, which could not be fully explained by the pathogenesis of tumor seeding and direct implantation. A possible explanation as published by Lorenz et al. is that after tumor seeding or direct implantation, the tumor cells may become dormant leading to several years of disease-free interval. In our case, the dormant tumor cells may have been trapped in the microcirculation of the abdominal incision site and were reactivated after 9 years which lead to tumor recurrence.
Published case reports and literature review showed that the interval from primary treatment to incision site recurrence may occur as early as 1 month to as late as 14 years., Due to the paucity of cases, there is no standard treatment for abdominal incision site recurrence. The proposed treatments were chemotherapy, hormone therapy with progestin, and radiotherapy. However, the cornerstone for all reported patients was complete surgical resection. The case presented underwent wide excision of the abdominal mass, but a 2-centimeter tumor-free margin was not attained, hence the suggestion of adjuvant chemotherapy. However, the patient did not consent.
| Conclusion|| |
Abdominal incision site recurrence is rare, with only a few case reports published. Abdominal wall recurrences must be taken into consideration when doing surgical treatment for endometrial cancer. Meticulous handling of the specimen must be observed to reduce the risk for tumor seeding. This case emphasizes the need for follow-up since recurrences may occur even several years after the primary surgery. There is no standard treatment to date due to the rare occurrence of abdominal wall recurrence. However, complete surgical resection seems to be the cornerstone of treatment in all reported cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]