Port-site recurrence in a patient undergoing robotic hysterectomy and lymph node dissection for endometrioid adenocarcinoma of the uterus
A 72-year old, multiparous woman presented with a history of postmenopausal bleeding for one year. Clinical examination revealed a 12 week size uterus and no adnexal masses. Two firm vaginal lesions measuring 1 cm each were noted at the vaginal fornix, in the 3 and 9 o'clock positions. A third similar lesion was noted in the lower third of the vagina in the 7 o'clock position. An endometrial biopsy showed a FIGO grade I endometrioid adenocarcinoma in a background of complex hyperplasia with atypia. CT abdomen and pelvis showed no evidence of extrauterine disease or lymphadenopathy. The patient was taken to the operating room for a robot-assisted laparoscopic hysterectomy with bilateral salpingo-oophorectomy, pelvic and paraaortic lymphadenectomy and excision of the lesion at the lower third of the vagina. A V-care uterine manipulator was placed. The da Vinci® surgical system (Intuitive Surgical) with 3 arms was used. A 12 mm supra-umbilical camera port and two 8 mm instrument ports were placed 10 cm lateral to the umbilicus and a 12 mm assistant port was placed at the right upper quadrant.\nCO2 pneumoperitoneum of 15 mmHg was maintained throughout the procedure. The first specimen included the uterus, fallopian tubes and ovaries and was removed intact through the vagina. The lymph nodes were removed through the assistant port. Specimen bags were not used. The operative time was 2.5 h and the estimated blood loss was 50 cm3. The final pathology was that of endometrioid type adenocarcinoma, FIGO Grade III (). The tumor size was 13 cm and the depth of invasion was 2 of 2.1 cm of myometrium (98%). No lymphovascular invasion was seen. The vaginal lesion was positive for metastatic endometrioid adenocarcinoma. Lymph nodes were negative.\nThe patient was assigned a FIGO (2009) stage IIIB ().\nThe postoperative treatment plan included whole pelvis radiation and interstitial brachytherapy followed by chemotherapy with Carboplatin and Taxol. The patient received external beam whole pelvic radiation therapy followed by interstitial brachytherapy. The port sites were outside the radiated field. At the completion of radiation, complete regression of the metastatic vaginal lesions was achieved. Three weeks later the patient reported pain on the abdominal wall at the site of the right lateral instrumental port.\nThe clinical exam revealed a 2 × 3 cm tender mobile subcutaneous nodule at the port site. A CT abdomen and pelvis was obtained and revealed tissue density in the abdominal wall at the site of the right lateral 8 mm port and no evidence of intraabdominal disease (). Chest X-ray was unremarkable. A local excision was performed in the operating room and the pathology confirmed recurrent endometrial adenocarcinoma of endometrioid type (). The peritoneal cavity was not breached during the excision of the port site tumor. One week later the patient presented to the emergency room with abdominal pain, nausea and vomiting. CT abdomen and pelvis was consistent with small bowel obstruction with transition point at the terminal ileum, probably due to radiation enteritis. A 1.7 cm × 1.3 cm hypodense lesion on the surface of the liver, not present on the previous scan was noted. She was admitted and conservative management with nasogastric suction and intravenous fluids was initiated. On the second day of her hospitalization, she was found unresponsive. An attempt for cardiopulmonary resuscitation was not successful. Possible cause of death is pulmonary embolism.