Recurrent ovarian dysgerminoma after laparoscopy 397
Recurrent ovarian dysgerminoma after laparoscopy S. PRADO*, R. YAZIGIy, J. GARRIDO*, M. GONZALEZ*, R. TORRESz & D. ODDO§ *Division of Gynecologic Oncology, National Cancer Institute, Santiago, Chile; yDivision of Gynecologic Oncology, Department of Obstetrics and Gynecology, Clinica Las Condes, Santiago, Chile; and Divisions of zMedical Oncology and §Pathology, National Cancer Institute, Santiago, Chile
Abstract.
Prado S, Yazigi R, Garrido J, Gonzalez M, Torres R, Oddo D. Recurrent ovarian dysgerminoma after laparoscopy. Int J Gynecol Cancer 2006;16(Suppl. 1):397–399.
To our knowledge, recurrent dysgerminoma at the site of tumor removal by laparoscopy in a patient with stage IA disease has not been previously reported. A woman with ovarian dysgerminoma treated by laparoscopy and tumor removed through the cul-de-sac recurred the 17 months later at the site of tumor removal. She was successfully treated with etoposide, bleomycin, and cisplatin chemotherapy with complete response. This case illustrates the potential for surgical site implant of an ovarian dysgerminoma; surgeons should follow strict guidelines when performing laparoscopic procedures for ovarian malignancies in order to prevent this type of incident. KEYWORDS:
dysgerminoma, laparoscopic surgery, ovarian cancer.
aged by laparoscopy, which later recurred at the site of tumor removal.
Laparoscopic surgery has constituted a major technical advance in the way we practice our specialty, allowing for faster patient recovery and diminished hospital stay and costs(1). Since its earlier reports by Ozols et al. and Berek et al.(2,3) in 1981, its use in ovarian cancer cases has continued to increase; however, this has been followed by a number of reports in the world literature describing recurrences at the surgical ports and at the sites of tumor removal(4). This risk seems to be greater when these procedures are performed by gynecologists who are not familiar with the basic oncology principles and who do not follow guidelines to prevent tumor dissemination(4,5). Recently, Abu-Rustum et al.(6) reported the largest and most up-to-date experience on trocar site and subcutaneous tumor implantation in ovarian cancer; they conclude that laparoscopy-related tumor implantation is rare and that this risk should not be used as an argument against laparoscopic procedures if patient selection is properly made by gynecologic oncologists. We present the first report to our knowledge of a patient with ovarian dysgerminoma, initially man-
Case M.V. is a 27-year-old woman who was admitted to the National Cancer Institute with the history of laparoscopic surgery 40 days prior to admission, which consisted of removal of an 8-cm solid left ovarian tumor, previously diagnosed by transvaginal ultrasound. The tumor was removed through the posterior culde-sac, an endopouch was not used, and no staging procedure was performed. The final pathology report revealed a pure dysgerminoma without capsular involvement. On admission, her physical examination, laboratory tests, chest X-rays, and abdominopelvic computed tomography scan were found to be unremarkable. A surgical staging procedure was then performed, which included peritoneal cytology, contralateral ovarian biopsy, omentectomy, ipsilateral lymphadenectomy, and para-aortic lymphadenectomy; all were found to be negative for tumor. Therefore, she was staged as IA pure dysgerminoma, and no further therapy was considered necessary. During one of her regular follow-up visits, 17 months after her initial surgery, a neoplastic lesion
Address correspondence and reprint requests to: Sebastian Prado, MD, Instituto Nacional del Ca´ncer, Casilla 70004, Correo 7, Santiago, Chile. Email:
[email protected] #
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398 S. Prado et al.
Table 1.
Immunohistochemistry
CD 45 (lymphocytic common antigen) CD 30 Pancytokeratin Carcinoembryonic antigen Placental alkaline phosphatase Alpha-fetoprotein
Negative Negative Negative Negative Positive Negative
was found arising from the posterior cul-de-sac, involving the posterior lip of the cervix (Fig. 1). Biopsy of this lesion and immunohistochemistry confirmed recurrent dysgerminoma (Figs. 2, 3) (Table 1). An abdominopelvic computed tomography scan showed no evidence of tumor elsewhere. She was then started on chemotherapy with cisplatin 100 mg/m2, etoposide 120 mg/m2, on days 1, 2, and 3 of each cycle, and bleomycin (30 IU on days 1, 8, and 15 of each cycle). After the first cycle, a 50% reduction of the tumor was noted; after the second cycle, the lesion was almost completely gone, except for a slight erosion at the posterior lip of the cervix (Fig. 4). After the third cycle, the cervix and cul-de-sac were entirely normal with no evidence of disease (Fig. 5). She then completed chemotherapy with an additional fourth cycle. She remains free of disease after 23 months of follow-up.
Discussion The use of laparoscopy in the management of ovarian tumors has continued to increase, based on the wellproven benefits of a minimally invasive procedure, allowing a magnified optical evaluation of the abdominal cavity(7). Since its earlier reports(2,3,8), technical refinements have made it a safer procedure for selected
Figure 1. Tumor arising from the posterior cul-de-sac involving the posterior lip of the cervix. #
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Figure 2. Clear cell malignant tumor with dysgerminoma appearance (H & E stain).
cases of ovarian tumors; nevertheless, several reports have shown that occasionally it may be the cause of complications that may threaten patient survival(9). The report of Abu-Rustum et al.(6) supports the fact that laparoscopic procedures are safe with proper case selection. They report only a 0.97% incidence of subcutaneous tumor implantation, which only occurs in patients with intraabdominal spread. This data suggest that laparoscopic procedures do not change the outcome of patients with advanced ovarian cancer. Nevertheless, the use of laparoscopy in oncology procedures present at least four problems that should be carefully avoided: the technique of tumor removal, avoidance of rupture during its dissection and removal,
Figure 3. Positive reaction for placental alkaline phosphatase (immunohisto chemistry study).
Recurrent ovarian dysgerminoma after laparoscopy 399
Table 2. Laparoscopic guidelines Careful case selection Team adequately trained for oncologic laparoscopic procedures Use of endopouch for removal of tumor Avoid tumor manipulation and subsequent rupture Peritoneal lavage at the completion of surgery Manage the puncture sites in the least traumatic manner Cleansing of the puncture sites and instruments with cytotoxic solutions (taurolidine-chlorhexidine) Avoid deflating pneumoperitoneum through diverse puncture sites Avoid instrument rotation in different ports Deflate pneumoperitoneum by aspiration Remove auxiliary trocars at the end of the surgical procedure Figure 4. Posterior lip of the cervix with slight erosion.
We agree with most authors that if strict guidelines are followed, laparoscopy is a safe procedure. Our case does not represent a laparoscopic complication but is related to inadequate handling of the specimen, which contaminated the surgical site. Every aspect of adequate surgical technique should be carefully followed. We have to conclude that when managing an ovarian tumor with laparoscopy, no laboratory tests and no particular age range or tumor characteristics should dissuade us from taking all the necessary steps to prevent complications derived from a possible malignancy.
prevention of intraabdominal dissemination, and finally, prevention of recurrence at the puncture sites. There are several reports in the literature addressing these aspects, one of the most thorough being the one published by Canis et al.(10), in which he carefully describes how to diminish the incidence of tumor implants at the puncture sites. Table 2 contains a list of facts to have in mind in order to minimize costly errors in applying laparoscopic techniques for ovarian neoplasms. Several conclusions can be drawn from the initial management of our case: the gynecologists involved with the case assumed that the tumor was benign based on negative tumor markers and the patient’s age; consequently, the laparoscopic approach was not planned to avoid possible risks in case the tumor would turn out to be malignant; and last, a frozen section diagnosis was not obtained, which could have avoided a second surgical procedure and possibly a recurrence by resecting the tissue through which the tumor was extracted.
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Accepted for publication December 22, 2004
Figure 5. Normal cervix after third chemotherapy cycle. #
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