Abdominal wall metastasis in scar after open resection of an adrenocortical carcinoma
Nikhil Gupta,1 Umesh Bansal,2 Neha Mahajan,2 Maha Singh Yadav2 1Department of Surgery, Lady Hardinge Medical College, Delhi; 2Department of Surgery, ESI hospital, Basaidarapur, Delhi, India
Abstract
A 42-year-old man patient presented with progressively increasing, occasionally painful lump in the left upper and central abdomen. Investigations revealed well-defined capsulat- ed left adrenocortical carcinoma. Tumor was resected successfully along with left kidney. Tumor recurred in the abdominal surgical scar 1.5 years after surgery. We are reporting this case because of rarity of metastatic recurrence of an adrenocortical carcinoma in the abdomi- nal surgical scar 1.5 years after resection of primary tumor.
Introduction
Metastasis of a tumor in the abdominal wall after open surgery is rare and has been report- ed mostly after resection of colorectal carcino- ma and hepatocellular carcinoma. Implant in the abdominal wall may occur as result of seed- ing from percutaneous biopsy of an intra abdominal malignancy or by tracking of tumor cells via an indwelling drain for malignant bil- iary obstruction. In recent years, an increasing number of abdominal wall recurrences of malignant colorectal, liver, gall bladder, ovari- an and pancreatic tumors have been docu- mented.
Case Report
In March 2009, a 42-year-old man patient presented with progressively increasing, occa- sionally painful lump in the left upper and cen- tral abdomen for past 2 months. On physical examination there was a hard, partially mobile, mildly tender 10×10 cm lump with irregular surface occupying the left lumber, left central abdomen and part of left hypochondri- um. Contrast-enhanced computed tomography (CECT) abdomen revealed well-defined capsu- lated heterogeneous soft tissue density lesion with evidence of calcification and patchy con-
trast enhancement, superior to left kidney (size 164×111×174 mm); no metastasis or lymphadenopathy was there. Computed tomog- raphy (CT) - guided true cut biopsy revealed adrenocortical carcinoma. Biochemical exami- nation was consistent with nonfunctioning tumor. In April 2009 the tumor was resected encapsulated along with left kidney (i.e. no rupture of capsule or spillage of tumor occurred). Histological analysis of specimen showed adrenocortical carcinoma with focal areas of capsular invasion and left kidney was unremarkable. No adjuvant chemotherapy was given. The patient was discharged from hospi- tal after eight days. Patient was followed up in out patient’s department for 6 months but then patient stopped coming to outpatient depart- ment for follow up.
In October 2010, patient presented with swelling in anterior abdominal wall rapidly increasing for last 2 months (Figure 1). Patient was not having any symptoms apart from mild pain locally. On physical examina- tion, there was a single hard, well defined, immobile, mildly tender 80×70 mm lump with irregular and bleeding surface occupying umbilical region. CECT thorax and abdomen was done which revealed a soft tissue mass lesion in the anterior abdominal wall at umbil- ical level involving the anterior abdominal wall muscle (B/L rectus abdominis), subcutaneous tissues and overlying skin with small calcific foci within, measuring 64.7×66×54 mm (Figure 2). There was no extension beyond the muscle. Cytological features were consistent with metastatic adrenocortical carcinoma (Figure 3). There was no evidence of metasta- sis elsewhere.
Patient was diagnosed as metastatic adrenocortical carcinoma so resection and abdominal wall reconstruction was planned but patient refused for any kind of treatment and opted for some indigenous medicines for his disease. After 2 months, he was brought to casualty department in state of shock with pro- fuse bleeding from tumor site. Despite exten- sive resuscitation, patient couldn’t be sal- vaged.
Discussion
Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy (incidence 1- 2 per 1 million populations) with a heteroge- neous presentation and a variable but generally poor prognosis.1 Women are more affected than men (ratio 1.5) and the age distribution is reported as bimodal with a first peak in child- hood and a second higher peak in the fourth and fifth decade.2 Men develop nonfunctioning malignant adrenocortical tumor more often than women. In stages I - III open surgery by an
Correspondence: Nikhil Gupta, Department of Surgery, Lady Hardinge Medical College, Delhi, India. E-mail: nikhil_ms26@yahoo.co.in
Key words: adrenal cortex, carcinoma, abdominal wall metastasis.
Received for publication: 14 November 2011. Revision received: 29 November 2011. Accepted for publication: 12 December 2011.
This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0).
@Copyright N. Gupta et al., 2012 Licensee PAGEPress, Italy Clinics and Practice 2012; 2:e9 doi:10.4081/cp.2012.e9
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expert surgeon aiming at an R0 resection is the treatment of choice.2 Local recurrence is fre- quent, particularly after violation of tumor cap- sule. Surgery also plays a role in local tumor recurrence and metastatic disease.
Abdominal wall metastases after open resec- tion of colorectal cancer occurs in 0.6% - 2.5% of all patients.3-5 A number of variables affect the incidence of recurrences, including stage of tumor and extent of manipulation during oper- ation. There is single reported case by van Grevenstein et al. describing abdominal wall metastasis 4.5 years after open resection of an adrenocortical carcinoma (during removal of tumor the capsule ruptured and there was some spill).6 There are two reported cases of recurrences after laparoscopic resection of an adrenocortical carcinoma. Hamoir et al. report- ed a case of massive peritoneal recurrence six month after laparoscopic resection of a rup- tured adrenocortical carcinoma with a diame- ter of 12 cm7 The other case was described by Foxius et al. and had a peritoneal recurrence six month after laparoscopic adrenalectomy for a supposed Conn’s adenoma, 2 cm in diameter.8
It is of utmost importance to leave the tumor capsule intact, thereby avoiding tumor spillage and reducing risk for local recurrence.1 CO2 insufflation of the abdomen during laparo- scopy may cause spread of the tumor cells with
subsequent peritoneal carcinomatosis. In experimental studies, gasless laparoscopy has been shown to be associated with fewer tumor deposits than laparoscopy with CO2 insuffla- tions.9 At present, there is a consensus that open adrenalectomy remains the operation of choice for ACC with invasion of adjacent organs, enlarged regional lymph nodes, or tumor larger than 10-12 cm in size.2
Our patient had a non-functioning adreno- cortical carcinoma. The surgery was unevent- ful i.e. no rupture and spillage of tumor cells. There might be possibility of spillage of some tumor cells during CT - guided true cut biopsy, which caused recurrence.
References
1. Dackiw AP, Lee JE, Gagel RF, Evans DB. Adrenal cortical carcinoma. World J Surg 2001;25:914-26.
2. Allolio B, Fassnacht M. Clinical review: Adrenocortical carcinoma: clinical update. J Clin Endocrinol Metab 2006;91:2027-37.
3. Cass AW, Million RR, Pfaff WW. Patterns of recurrence following surgery alone for adenocarcinoma of the colon and rectum. Cancer 1976;37:2861-5.
4. Hughes ES, McDermott FT, Polglase AL, Johnson WR. Tumor recurrence in the abdominal wall scar tissue after large- bowel cancer surgery. Dis Colon Rectum 1983;9:571-2.
5. Reilly WT, Nelson H, Schroeder G, et al. Wound recurrence following conventional treatment of colorectal cancer. A rare but perhaps underestimated problem. Dis Colon Rectum 1996;39:200-7.
6. van Grevenstein WMU, de Krijger RR, de Herder WW, et al. Abdominal wall metasta- sis after open resection of an adrenocorti- cal carcinoma. Eur J Surg 2001;167:871-3.
7. Hamoir E, Meurisse M, Defechereux T. [Is laparascopic resection of a malignant cor- ticoadrenaloma feasible? Case report of early, diffuse and massive peritoneal recurrence after attempted laparoscopic resection]. Ann Chir 1998;52:364-8. [Article in French].
8. Foxius A, Ramboux A, Lefebvre Y, et al. Hazards of laparoscopic adrenalectomy for Conn’s adenoma. When enthusiasm turns to tragedy. Surg Endosc 1999;13:715-7.
9. Bouvy ND, Marquet RL, Jeekel H, Bonjer HJ. Impact of gas(less) laparoscopy and laparotomy on peritoneal tumor growth and abdominal wall metastases. Ann Surg 1996;224:694-701.
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