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Ann Thorac Surg 2001;71:1032-1034
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
Accepted for publication September 7, 2000.
Address reprints requests to Dr Freeman, Division of Thoracic and Cardiovascular Surgery, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas 75235-8879
e-mail: rkfreeman{at}pol.net
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A 51-year-old man with a 30-year history of untreated reflux pyrosis presented to another medical facility with a 6-week history of progressive dysphagia. He also admitted to occasional odynophagia and a 65-pound weight loss over the previous 2 months. His review of systems was otherwise unremarkable. The patient had been previously treated with a proton pump inhibitor for peptic ulcer disease, had abused alcohol in the past, and had smoked two packs of cigarettes per day for the last 35 years. He had undergone no prior surgery. His laboratory evaluation found normal electrolytes including calcium and phosphorous, normal liver enzymes, and a hematocrit of 42%. A chest radiograph revealed no abnormalities.
A barium esophagram was performed which demonstrated a dilated proximal esophagus with an 8-cm distal stricture that terminated at the gastroesophageal junction. Flexible esophagoscopy found the stricture contained a 2-cm circumferential mass located 3 cm from the gastroesophageal junction beyond which the endoscope could not be negotiated. Biopsies were obtained which on histologic analysis were found to be consistent with poorly differentiated adenocarcinoma invading the muscularis mucosa of the esophagus. Computed tomographic imaging of the chest and abdomen displayed no evidence of intrathoracic or intraabdominal lymphadenopathy, pulmonary nodules, or hepatic metastases. Endoscopic ultrasound could not be performed because the probe could not be passed through the lesion.
A laparoscopic staging procedure was then performed. The operating surgeons confirmed that this consisted of the placement of a 10-mm supraumbilical camera port and a single 5-mm epigastric instrument port through which the peritoneal and diaphragmatic surfaces as well as the liver were inspected for evidence of metastatic disease. Although no biopsies were taken, the area of the celiac lymph node basin and gastroesophageal junction were minimally manipulated in search of adenopathy or direct tumor extension respectively. The peritoneal cavity was then lavaged with saline for cytologic evaluation.
Because no evidence of metastatic disease was found on visual inspection or cytology, the patient was referred to our cancer center for consideration of neoadjuvant chemoradiation therapy with a pretreatment stage IIA (T3N0M0) adenocarcinoma of the esophagus. He underwent synchronous 5-fluorouracil and cisplatinum chemotherapy concurrently with fractionated external beam radiation. Posttreatment evaluation with computed tomographic imaging of the abdomen and chest along with flexible esophagoscopy found no progression of his esophageal malignancy.
Three months after the initial diagnosis of esophageal adenocarcinoma the patient underwent a radical esophagectomy to the level of the azygos vein with an esophagogastrostomy. During the celiotomy a peritoneal nodule was excised from the previous epigastric instrument port site. Frozen section analysis of this nodule was indeterminate. No other peritoneal surface abnormalities were found on exploration of the entire peritoneal cavity. The patient experienced an uneventful postoperative course and was discharged home on postoperative day 7.
Analysis of the permanent pathology sections revealed that the tumor was a poorly differentiated adenocarcinoma with signet ring features that extended into omental fat. Metastatic adenocarcinoma was found in six celiac lymph nodes and the surgical resection margins were free of tumor. Poorly differentiated adenocarcinoma with signet ring features was also found in the peritoneal nodule excised from the previous supraumbilical port site resulting in a pathologic stage IV (T4N0M1A) cancer of the esophagus (Fig 1).
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Enthusiasm for the use of minimally invasive surgery in the diagnosis and treatment of other intraabdominal and intrathoracic malignancies has, however, decreased after reports of tumor metastases at port sites. Port site metastases have been reported after videoscopic resections involving malignancies of the lung, pleura, esophagus, stomach, gallbladder, appendix, colon and rectum, and ovary [2]. The etiology of such metastases appear to be multifactorial with tissue trauma and CO2 leakage at port sites, excessive tumor manipulation or perforation, and lack of protective measures during tumor extraction all having been shown to increase the incidence of these metastases in clinical series and animal models [3, 4].
Although a recent review would suggest that patient survival may decrease significantly between M1A and M1B esophageal carcinoma, the recognition of an abdominal port site metastasis after laparoscopic staging in a patient with esophageal carcinoma raises other important issues as well [5]. Although we could find no previous report in the literature of this type of port site metastasis, it is unlikely that this is the first time that such an event has occurred. The inability to distinguish between port site metastases and other peritoneal tumor implants, the significant number of patients who do not undergo resection or palliation after minimally invasive esophageal cancer staging, and the lack of routine histologic evaluation of port sites at subsequent operations could all lead to underreporting the frequency of port site metastases.
Without certainty as to the true incidence of port site metastases or their effects (if any) on patient survival, it would seem prudent to limit the use of minimally invasive staging of esophageal malignancies to clinical research protocols as has been done to evaluate other minimally invasive forms of oncologic surgery. Such protocols could be written or amended to include compulsory biopsy of the peritoneal surfaces of all port sites for patients who require subsequent resection or surgical palliation. Only in this manner will it be possible to systematically assess the risks and benefits of this technique. Furthermore informed consent for patients undergoing minimally invasive staging should include the possibility of port site metastasis and the uncertainty of its effects on patient survival.
The recognition that port site metastases are possible after laparoscopic staging for esophageal carcinoma should also serve to focus surgeons’ attention on the prevention of these metastases. Protecting port site tissues by using specimen bags for tissue extraction has become the standard of care when performing minimally invasive surgery for malignancy. Attempts to eliminate tumor seeding using topical and systemic cytotoxic medications have produced mixed results in animal models [6]. However irrigation of videoscopic ports with povidone-iodine (Betadine, Purdue Frederick, Norwalk, CT) has been shown to greatly reduce or eliminate port site metastases in animals when compared to local cytotoxic medications. Povidone-iodine is also inexpensive, is readily available, and does not appear to have any long-lasting detrimental effects on wound healing [7].
In summary, port site metastases after laparoscopic staging of esophageal carcinoma can in fact occur; they are likely to be underreported and their effects on patient survival are not currently known. Minimally invasive staging of esophageal malignancies should therefore continue to be investigated using research protocols that require histologic evaluation of port sites during subsequent surgery and address issues of informed consent. Surgeons who have significant experience using minimally invasive techniques to stage esophageal malignancy should be encouraged to report the incidence (if any) of port site metastases. Finally, along with other protective measures, all port sites should be irrigated with a solution containing povidone-iodine at the conclusion of minimally invasive staging procedures for esophageal cancer in an attempt to minimize the number of viable tumor cells left behind.
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This article has been cited by other articles:
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  P. A. Paraskeva, S. Purkayastha, and A. Darzi Laparoscopy for Malignancy: Current Status Surgical Innovation, March 1, 2004; 11(1): 27 - 36. [Abstract] [PDF]
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