Isolated port‐site prostate metastasis after robot‐assisted laparoscopic radical prostatectomy

Abstract

Isolated port-site prostate metastasis after robot-assisted laparoscopic radical prostatectomyThe incidence of port-site metastasis due to tumour seeding in urooncological surgery ranges from 0.09% to 0.73%, which is similar to rates of tumour seeding in open surgery. 1,2 A port-site metastasis is defined as a tumour recurrence localized within the abdominal wall, at or near a laparoscopic trocar entry site, and is not associated with widespread peritoneal carcinomatosis. 3 We present a case of port-site metastasis after robot-assisted laparoscopic radical prostatectomy (RALRP).A 65-year-old New Zealand Maori male presented with a rising prostate-specific antigen (PSA) of 10.5 ng/mL and clinical T2 stage. Past medical history includes asthma and right foot fusion. He did not consume alcohol or smoke cigarettes. Transrectal prostate biopsies reported adenocarcinoma, Gleason score 6 (3 + 3) on the left prostate, measuring 2.4 mm, involving 4% of tissue. Highgrade prostatic intraepithelial neoplasia, perineural invasion or extra prostatic tissue involvement were absent. The right prostate had benign prostatic tissue. Bone and computed tomography (CT) scans were negative for malignancy. After discussing options, the patient underwent RALRPhistology reported acinar type adenocarcinoma, pT2cNxMx, Gleason 7 (3 + 4) with negative surgical margins. Seminal vesicles were not involved and perineural and capsular invasion were absent. A separate lateral margin of prostatic tissue was taken via a lateral port site, showing adenocarcinoma -Gleason score 8 (4 + 4). The surgery was a standard RALRP with oncological barrier type removal and no complications. Six weeks following surgery, his PSA was 0.3 ng/mL. A positron emission tomography/CT scan showed no metastatic disease. He proceeded for salvage radiotherapy to the prostate bed 5 months post surgery and his PSA was <0.1 ng/mL 6 months after radiotherapy.Three years after RALRP and 2.5 years after radiotherapy, his PSA started to rise gradually over 1 year, reaching 1.2 ng/mL. A small intensely prostate-specific membrane antigen-positive focus within the right internal oblique muscle was reported on a prostatespecific membrane antigen positron emission tomography/CT scan (Fig. 1). No local tumour recurrence in the prostate bed, locoregional pelvic lymph node metastases or distant metastases was identified. The lesion measured 9-mm on magnetic resonance imaging and showed malignant epithelial cells positive for PSA on fine needle aspiration.The palpable lesion on the right anterolateral abdominal wall musculature was excised (Fig. 2 shows the surface anatomy). This was located near the lateral port side from which prostatic tissue was removed. The lesion showed metastatic tumour with strong and diffuse positive staining for PSA and focal positive staining for CK20features consistent with metastatic prostatic adenocarcinoma with negative margins (Fig. 3). Repeat PSA at 6 weeks after surgery was 0.4 ng/mL and has been rising by 0.1

Tumor Seeding after Robot-Assisted Radical Prostatectomy: Literature Review and Experience from a Single Institution

“…In particular PSMA PET/CT was able to show recurrence even with PSA levels of approximately 1 ng/ml. 10,11 In our cases choline PET/CT was performed in all patients and was able to detect port site metastases with PSA ranging from 1.5 to 4.3 ng/ml, but did not reveal peritoneal studding.…”

Peritoneal and port site seeding of an undiagnosed urothelial carcinoma of the bladder after robot-assisted laparoscopic prostatectomy

“…A systematic review of port site metastases after robot-assisted surgery revealed histological variance in cases involving surgical device seeding, such as cervical squamous cell carcinoma and adenocarcinomas, gallbladder carcinoma, and urothelial cell carcinoma [11] . Additional primaries associated with port site metastases and seeding events after robot-assisted surgery have been described for renal cell carcinoma, prostate adenocarcinoma, and endometrial carcinoma [4] , [5] , [6] , [7] , [8] , [9] , [13] , [14] .…”

“…Case reports described port site and peritoneal seeding after laparoscopic and/or RALP with prostate adenocarcinoma and an undiagnosed case of pancreatic adenocarcinoma. [4] , [5] , [6] , [7] , [8] , [9] However, we present a case report of an unusual peritoneal and port site seeding by an undiagnosed urothelial carcinoma of the bladder after RALP for localized prostate cancer.…”

Port-Site Metastasis Identified on Prostate-Specific Membrane Antigen–Targeted 18F-DCFPyL PET/CT After Robot-Assisted Laparoscopic Radical Prostatectomy

“…[5][6][7][8][9] Of the molecular imaging tools available for prostate cancer, PSMA PET/CT has a clear advantage in detecting early recurrence at lower PSA levels. 5,6 Herein, we illustrate the advantage of the newly Food and Drug Administration-approved PSMA PET ligand 18 F-DCFPyL in identifying such rare patterns of prostate cancer recurrence.…”

“…Of these, 3 were from their own institution, 9 were identified from a systematic literature review, and 7 cases occurred post–robot-assisted laparoscopic radical prostatectomy 4 . Given its higher sensitivity and specificity, molecular imaging was often the modality to make or suggest the correct diagnosis among case reports of prostate cancer port-site metastasis 5–9 . Of the molecular imaging tools available for prostate cancer, PSMA PET/CT has a clear advantage in detecting early recurrence at lower PSA levels 5,6 .…”