Port-site metastasis of prostatic adenocarcinoma is rare and usually associated with poor prognosis. We report a case of a young man with a rising prostate-specific antigen (PSA) 4.5 years after robotassisted laparoscopic prostatectomy (RALP) and extended pelvic lymphadenectomy (ePLND) for a Gleason 7 (4+3) prostate cancer (pT3b pN0 cM0). Choline positron emission tomography-computed tomography (PET-CT) demonstrated a PET positive subcutaneous recurrence in a previous trocar site accompanied by a PET positive ipsilateral inguinal lymph node. Excision of both lesions was performed, confirming the diagnosis of metastatic prostate cancer. The patient's PSA dropped significantly postoperatively enabling postponement of androgen deprivation treatment up to this date. The etiology of port-site metastasis is multifactorial, including patient and surgery related factors. Such metastases have been scarcely reported following ePLND with or without RALP. Certain surgical precautions can be made to prevent the occurrence. We summarize previously reported mechanisms of development and possible precautionary measures.
Case reportA 46-year-old male presented to our clinic with a rise in prostate-specific antigen (PSA) (32.8 ng/mL). Transrectal biopsies were performed, revealing prostate cancer Gleason 7 (4+3) on the right side. Staging by means of abdominal computed tomography (CT) and bone scintigraphy were negative. He underwent a non-nerve sparing robot-assisted radical prostatectomy along with an extended pelvic lymphadenectomy. The specimen was extracted in an endobag using the supra-umbilical camera port. Anatomopathological examination confirmed prostate cancer pT3b pN0 (0/19) cM0, Gleason 7 (4+3). There was extracapsular extension and seminal vesicle invasion on the right. Surgical margins were negative. Three months after surgery, PSA had dropped to 0.015 ng/mL, but started to rise 3 months later to 0.019 ng/mL.PSA surveillance continued (Table 1) and by the 25th month postoperative PSA had risen to 0.15 ng/mL. Digital rectal examination revealed nothing suspicious and the patient was referred for adjuvant salvage intensity-modulated radiation therapy (IMRT) on the prostatic bed (total dosage 71.26 Gy) along with 6 months of luteinizing hormone releasing hormone-agonists treatment. PSA dropped to <0.03 ng/mL only to start rising again 1 year later (0.041 ng/ mL). PSA continued to rise progressively causing the need for various staging investigations. Finally about 4.5 years after the initial surgery, a repeat choline positron emission tomography-computed tomography (PET-CT) demonstrated opacification of a subcutaneous mass in the left flank along with an ipsilateral inguinal lymph node (Fig. 1, Fig. 2).PSA was now at 10.15 ng/mL. Clinically, we palpated a mass in the left flank just close to one of our previous lateral trocar incisions, accompanied by an ipsilateral inguinal lymph node. The patient underwent excision of both (Fig. 3). Anatomopathological examination confirmed subcutaneous and lymphatic metasta...