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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 73-75

Isolated incisional recurrence in a patient with early-stage endometrial cancer: A case report and review of the literature


Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan

Date of Submission15-Aug-2018
Date of Decision19-Oct-2018
Date of Acceptance19-Nov-2018
Date of Web Publication29-Apr-2019

Correspondence Address:
Dr. Soshi Kusunoki
Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_81_18

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  Abstract 


Isolated incisional recurrence in a patient with early-stage endometrioid carcinoma is extremely rare. The mechanism of this recurrence also remains unclear. We describe a case of an isolated incisional recurrence of endometrioid carcinoma from the uterine corpus 4 years after the primary surgery. We review the previous literature and discuss the possible mechanism of isolated incisional recurrence. A 56-year-old woman diagnosed with the International Federation of Gynecology and Obstetrics Stage IA and Grade 2 endometrioid carcinoma in the uterine corpus showed an isolated cystic mass in the abdominal wall 4 years after the primary surgery. She underwent resection of the abdominal tumor, and the pathological findings showed endometrioid carcinoma, which was the same as the primary tumor. She received chemotherapy and remained disease free 8 months after chemotherapy. Long-term follow-up is required to detect recurrence, even in patients with early-stage uterine corpus carcinoma.

Keywords: Endometrioid cancer, isolated incisional recurrence, metastasis


How to cite this article:
Hirayama T, Kusunoki S, Fujino K, Terao Y, Itakura A. Isolated incisional recurrence in a patient with early-stage endometrial cancer: A case report and review of the literature. Gynecol Minim Invasive Ther 2019;8:73-5

How to cite this URL:
Hirayama T, Kusunoki S, Fujino K, Terao Y, Itakura A. Isolated incisional recurrence in a patient with early-stage endometrial cancer: A case report and review of the literature. Gynecol Minim Invasive Ther [serial online] 2019 [cited 2019 Jun 26];8:73-5. Available from: http://www.e-gmit.com/text.asp?2019/8/2/73/257338




  Introduction Top


Endometrioid carcinoma is one of the most common female genital cancers and is well known for its good prognosis. The 5-year overall survival (OS) rate is approximately 80% in the developed countries.[1] In cases of the International Federation of Gynecology and Obstetrics (FIGO) Stage IA, the 5-year OS rate is higher than 90%.[2] Furthermore, in the pathological aspect, patients with endometrioid carcinoma show better prognosis (5-year OS: 83%) than those with clear cell carcinoma (62%) and serous carcinoma (53%), regardless of the FIGO stage.[1] Recurrence mainly occurs locoregionally, such as in the vaginal stump or pelvic sidewall,[3] and an incisional recurrence occurs in approximately 0.1% of patients with endometrial carcinoma.[4] In addition, isolated incisional recurrence in a patient with early-stage endometrioid carcinoma is extremely rare.[4] Therefore, the mechanism of this recurrence remains unknown.

Here, we report a patient with endometrioid carcinoma in the uterine corpus diagnosed with FIGO Stage IA and Grade 2 through histological findings, who showed isolated incisional recurrence 4 years after the primary surgery. We review the previous literature and discuss the possible mechanism of the isolated incisional recurrence.


  Case Report Top


A 56-year-old woman, gravida 3, para 2, underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for endometrial cancer at the age of 52 years. The pathological findings revealed a Grade 2 endometrioid carcinoma in the uterine corpus [Figure 1]a. The depth of myometrial invasion was <1/2, and no lymphovascular space invasion was noted. Although there was no evidence of extrauterine metastases, the cytology on peritoneal ascites was positive. The tumor was classified as FIGO Stage IA, Grade 2 endometrioid carcinoma, and the patient received five courses of adjuvant chemotherapy with paclitaxel (150 mg/m2), doxorubicin (40 mg/m2), and carboplatin (area under the curve = 4) every 3 weeks in accordance with our algorithm. After the treatment, the patient was routinely followed up; she underwent testing for the levels of the tumor marker cancer antigen (CA) 125 every 3 months and underwent computed tomography (CT) annually. Forty-eight months after the last chemotherapy session, her CA125 level was found to have elevated rapidly and suddenly; magnetic resonance imaging (MRI) revealed a 9 cm × 7 cm polycystic mass arising in the abdominal wall [Figure 2]a, and 18F-fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) showed an increased uptake in the mass (maximum standardized uptake value: 15.69) [Figure 2]b. No other lesion that was suspicious for metastasis was found. Resection of the abdominal wall mass and repair of the abdominal wall defect were performed using the fascia lata. During the laparotomy with incision of the primary surgery, the abdominal wall mass was found in the rectus abdominis muscle, and it invaded the fascia lata but not the intra-abdominal cavity macroscopically. Similarly, the recurrent tumor found in the muscle did not penetrate the peritoneum and did not reach the abdominal cavity microscopically. No other recurrent tumor was observed in the abdominal cavity. Histopathology of the resected mass revealed an endometrioid carcinoma metastasis [Figure 1]b, and the surgical margins were negative. Cytology of ascites was positive. The patient received six courses of adjuvant chemotherapy with paclitaxel (175 mg/m2) and carboplatin (area under the curve = 5) every 3 weeks. The patient remained disease free 8 months after completing chemotherapy.
Figure 1: Pathological findings. (a) H and E staining revealing Grade 2 endometrioid carcinoma (H and E, ×200), (b) abdominal wall recurrent tumor: same histology (H and E, ×200)

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Figure 2: Tumor appearance. (a) Contrast-enhanced magnetic resonance imaging, T2-weighted axial aspect, showing polycystic mass arising from the abdominal wall (arrow), (b) 18F-fluorodeoxyglucose-positron emission tomography/computed tomography showing an increased uptake in the mass (maximum standardized uptake value: 15.69) (arrow)

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  Discussion Top


The recurrence of uterine corpus cancer mainly occurs in the vaginal stump or pelvis, and isolated incisional recurrence is extremely rare.[4] We could only find 43 cases of this recurrence pattern in the literature; among them, only 18 cases involved isolated abdominal wall recurrence. Moreover, only 9 cases were classified as FIGO Stage IA [Table 1],[5],[6],[7],[8],[9],[10],[11],[12],[13] and the patients were thus at low risk for recurrence, which is similar to that in our case. Since isolated incisional recurrence of uterine corpus cancer is extremely rare, the mechanism and pathway of recurrence remain unknown. Most previous reports suggest possible mechanisms such as hematogenous metastasis, intraperitoneal spread, and tumor implantation during surgery. In cases of advanced-stage cancer, hematogenous or lymphogenous metastasis or implantation in the abdominal wall could occur. However, the reason why the recurrence did not occur in the vaginal stump or pelvis but in the solitary abdominal wall in our case, as well as in those cases described in [Table 1], cannot be explained. All these cases were classified as early-stage endometrial cancer with the patients exhibiting a low risk of recurrence. In our case, because the cytology of ascites during the primary surgery was positive, the mechanism of isolated incisional recurrence might be tumor implantation during the primary surgery. This means that cancer cells implanted in the abdominal wall during the primary surgery remained dormant for 4 years but were later activated because of some triggering factors. There is an interesting hypothesis that explains the causes of its activation from dormancy, namely inflammatory oncotaxis. It is an alternative recurrent mechanism proposed by DerHagopian et al.[14] and suggests that mechanical trauma or stress leads to the proliferation of preexisting dormant micrometastases, allowing for angiogenesis, formation of supportive stroma, and immune evasion through inflammatory cytokines and some growth factors.[15],[16] In our case, although the episode causing trauma or stress was unclear, the patient had been receiving treatment for diabetes. It means that she was in an immunosuppressed state. One of the two patients with inflammatory oncotaxis reported by Walter et al. also had diabetes.[6] That is to say, in our case, the immunosuppressed state caused by diabetes could have contributed to the activation of the implanted cancer cells during primary surgery in the dormant state through inflammatory oncotaxis and resulted in the isolated incisional recurrence.
Table 1: Characteristic of FIGO Stage I A endometrial carcinoma patients with isolated incisional recurrence

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Bogani et al. showed that isolated incisional recurrence conferred significantly better OS than nonisolated incisional recurrence.[4] In our case, since the cytology of ascites during the surgery was positive, we administered systemic chemotherapy after complete resection. The efficacy of adjuvant chemotherapy after the resection of isolated incisional recurrence has not been established yet. Therefore, long-term follow-up is required for the assessment of treatment.


  Conclusion Top


Isolated incisional recurrence of early-stage endometrial cancer is extremely rare, and the mechanism of this recurrence is still unknown. Nevertheless, long-term follow-up is required even in patients with early-stage cancer to detect recurrence.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Colombo N, Preti E, Landoni F, Carinelli S, Colombo A, Marini C, et al. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2011;22 Suppl 6:vi35-9.  Back to cited text no. 1
    
2.
Werner HM, Trovik J, Marcickiewicz J, Tingulstad S, Staff AC, Amant F, et al. Revision of FIGO surgical staging in 2009 for endometrial cancer validates to improve risk stratification. Gynecol Oncol 2012;125:103-8.  Back to cited text no. 2
    
3.
Topfedaisi Ozkan N, Meydanlı MM, Sarı ME, Demirkiran F, Kahramanoglu I, Bese T, et al. Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone. J Gynecol Oncol 2017;28:e65.  Back to cited text no. 3
    
4.
Bogani G, Dowdy SC, Cliby WA, Gostout BS, Kumar S, Ghezzi F, et al. Incisional recurrences after endometrial cancer surgery. Anticancer Res 2015;35:6097-104.  Back to cited text no. 4
    
5.
Barter JF, Hatch KD, Orr JW Jr., Shingleton HM. Isolated abdominal wound recurrence of an endometrial adenocarcinoma confined to a polyp. Gynecol Oncol 1986;25:372-5.  Back to cited text no. 5
    
6.
Kotwall CA, Kirkbride P, Zerafa AE, Murray D. Endometrial cancer and abdominal wound recurrence. Gynecol Oncol 1994;53:357-60.  Back to cited text no. 6
    
7.
Khalil AM, Chammas MF, Kaspar HJ, Shamseddine AI, Seoud MA. Case report: Endometrial cancer implanting in the laparotomy scar. Eur J Gynaecol Oncol 1998;19:408-9.  Back to cited text no. 7
    
8.
Muntz HG, Goff BA, Madsen BL, Yon JL. Port-site recurrence after laparoscopic surgery for endometrial carcinoma. Obstet Gynecol 1999;93:807-9.  Back to cited text no. 8
    
9.
Lorenz U, Gassel AM, Thiede A, Gassel HJ. Endometrial carcinoma recurrence in an abdominal scar 14 years after total hysterectomy. Gynecol Oncol 2004;95:393-5.  Back to cited text no. 9
    
10.
Chen CC, Straughn JM Jr., Kilgore LC. Early abdominal incision recurrence in a patient with stage I adenocarcinoma of the endometrium. Obstet Gynecol 2004;104:1170-2.  Back to cited text no. 10
    
11.
Palomba S, Falbo A, Russo T, La Sala GB. Port-site metastasis after laparoscopic surgical staging of endometrial cancer: A systematic review of the published and unpublished data. J Minim Invasive Gynecol 2012;19:531-7.  Back to cited text no. 11
    
12.
Santeufemia DA, Lumachi F, Basso SM, Tumolo S, Re GL, Capobianco G, et al. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy as salvage treatment for a late wound recurrence of endometrial cancer. Anticancer Res 2013;33:1041-4.  Back to cited text no. 12
    
13.
Grabosch S, Xynos F. Isolated port-site metastasis after robotic hysterectomy for stage IA endometrial adenocarcinoma. Obstet Gynecol 2013;122:437-9.   Back to cited text no. 13
    
14.
DerHagopian RP, Sugarbaker EV, Ketcham A. Inflammatory oncotaxis. JAMA 1978;240:374-5.  Back to cited text no. 14
    
15.
Walter ND, Rice PL, Redente EF, Kauvar EF, Lemond L, Aly T, et al. Wound healing after trauma may predispose to lung cancer metastasis: Review of potential mechanisms. Am J Respir Cell Mol Biol 2011;44:591-6.  Back to cited text no. 15
    
16.
Hirai T, Matsumoto H, Kubota H, Yamaguchi Y. Regulating surgical oncotaxis to improve the outcomes in cancer patients. Surg Today 2014;44:804-11.  Back to cited text no. 16
    


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