Abdominal wall metastases from ovarian cancer

after laparoscopy
Noreen C. Gleeson, MD," Santo V. Nicosia, MD, MS,b James E. Mark, MD,"
Mitchel S. Hoffman, MD," and Denis Cavanagh, MD"
Tampa, Florida
We report three cases of abdominal wall metastases from ovarian cancer after laparoscopy. The implants
occurred at the site of insertion of laparoscopy trocars. One patient had an implant of serous papillary
carcinoma of low malignant potential at the trocar sites after Japaroscopic oophorectomy. Laparoscopic
surgery is inappropriate in patients with malignant ascites or when preoperative or intraoperative findings
are suggestive of ovarian cancer. (AM J OBSTET GVNECOL 1993;169:522-3.)

Key words: Laparoscopy, ovarian cancer, abdominal wall metastasis

The gynecologic applications of laparoscopy have

been extended to include selective cancers, and some
authorities even recommend it in the management of
stage I borderline cancers of the ovary. 1

Case reports
A 31-year old nulliparous white woman had a 4 cm
left adnexal mass noted on routine gynecologic examination, and it was confirmed to be a unilocular ovarian
cyst by ultrasonography. This cyst persisted over a
5-week period. In spite of the laparoscopic finding of
papillary excrescences on both ovaries, a left salpingooophorectomy and right ovarian biopsy were performed laparoscopically. The ovarian tissue was extracted from the abdominal cavity through the second
laparoscopic sleeve in the left lower quadrant. The
tumor was serous papillary tumor of low malignant
potential (borderline) in both ovaries. At staging laparotomy 2 weeks later we found a 2 cm subcutaneous
nodule in the left lower quadrant of the abdomen and
tumor deposits on the pelvic peritoneum. All visible
tumor was removed. Histopathologic examination confirmed the prior diagnosis with deposits on the peritoneum and in the subcutaneous tissue of the abdominal
wall. The patient is currently being treated with cisplatin and cyclophosphamide.
Two patients, aged 69 and 79 years, were referred to
our service after laparoscopy, which was performed in
the presence of clinically and ultrasonographically detected ascites. Ascites had been drained, and samples of
From the Division of Gynecologic Oncology, Department of Obstetrics
and Gynecology, University of South Florida, a and the Department of
Pathology, H. Lee Moffitt Cancer Center and Tampa General
Hospital.'
Received for publication February 5, 1993; revised March 5, 1993;
accepted April 15, 1993.
Reprint requests: Noreen C. Gleeson, Harbourside Medical Tower,
Suite 547, 4 Columbia Dr., Tampa, FL 33606.
Copyright 1993 by Mosby-Year Book, Inc.
0002-9378193 $1.00 + .20 6/1/48004

522

pelvic carcinomatosis were removed for biopsy in each

case. Histopathologic examination revealed poorly differentiated ovarian carcinoma and serous papillary carcinoma. Both patients were referred to our service
within 2 weeks of laparoscopy, and palpable subcutaneous masses up to 8 cm in diameter had developed at
one or two of the laparoscopic trocar sites by that time.
Staging laparotomy with optimal debulking 2 cm
residual) was performed. Removal of the abdominal
wall masses necessitated excision of the umbilicus and
repair of the rectus sheath defect with a synthetic mesh
in one case. Both patients were commenced on cyclic
carboplatin and cyclophosphamide chemotherapy.

Comment
Laparoscopic operative management of ovarian cysts
inevitably results in the removal of adnexal masses that
are subsequently found to be malignant, because gross
malignant features are not always present. 2 In the first
case presented, laparoscopic assessment of a 4 cm
unilocular ovarian cyst was appropriate, but laparoscopic removal of ovarian tissue in the presence of
bilateral surface excrescences, a feature highly suspicious for the presence of malignancy, resulted in seeding of the abdominal wall with tumor. Although this was
a tumor of low malignant potential otherwise confined
to the pelvis, the rapid growth of the abdominal wall
drop metastasis in this case suggested that this was a
biologically aggressive tumor, and we felt obligated to
offer adjuvant chemotherapy to this patient. Although
there are some reports of abdominal wall seeding after
laparoscopic biopsy, to our knowledge ours is the first
case report of abdominal wall seeding after laparoscopic oophorectomy in the presence of a serous ovarian tumor of low malignant potential. Displacement of
ovarian tumor to sites outside the peritoneal cavity may
remove it from restraining factors present in its natural

Belfort and Saade

Volume 169, Number 3

Am J Obstet Gynecol

intraperitoneal environment and account for the very

rapid growth seen in these metastases. Because paracentesis carries a risk of abdominal wall tumor seeding,
aspiration of malignant ascites is generally avoided
before staging laparotomy in ovarian cancer. Cutaneous
tumor nodules can occur in laparotomy scars, but careful irrigation of the wound after closure of the rectus
sheath probably minimizes this risk. In the second and
third cases presented the patients' chemotherapeutic
management was not altered by the presence of tumor
nodules, but the presence of tumor in the abdominal
wall may affect their prognosis. In addition, one patient
is left at a cosmetic disadvantage from removal of the
umbilicus. These patients may be at risk for abdominal
wall tumor recurrence, which is a distressing condition
because of its overt nature.
The contraindications to laparoscopic surgery are

well established, and these cases are principally indictments of poor surgical judgment. In the current wave of
enthusiasm for operative laparoscopy in gynecologic
malignancies, they serve as a reminder that laparoscopy
is contraindicated when ovarian cancer is present or
suspected. We disagree with the suggestion of Reich et
a1. 1 that laparoscopic staging is appropriate in borderline ovarian tumors. The role of operative laparoscopy
in the management of adnexal masses and perhaps
selected early ovarian cancers continues to evolve, but it
should proceed with extreme caution.
REFERENCES
1. Reich H, McGlynn F, Wilkie W. Laparoscopic management

of stage 1 ovarian cancer. J Reprod Med 1990;35:601-4.

2. Maiman M, Seltzer V, Boyce J. Laparoscopic excision of
ovarian neoplasms subsequently found to be malignant.
Obstet Gynecol 1991;77:563-5.

Retinal vasospasm associated with visual disturbance in

preeclampsia: Color flow Doppler findings
Michael A. Belfort, MD, and George R. Saade, MD
Houston, Texas
This case report demonstrates retinal vasospasm during a period of visual disturbance in a patient with
preeclampsia. Doppler assessment of the orbital vasculature was performed during and after the episode.
Central retinal artery blood velocity increased, and resistance decreased, after resolution of symptoms.
Visual disturbances in preeclampsia may be associated with retinal artery vasospasm and ischemia. (AM J
OBSTET GVNECOL 1993;169:523-5.)

Key words: Central retinal artery, Doppler

Visual disturbances, particularly flashes of light, have

frequently been reported in patients with preeclampsiaeclampsia. The cause of this symptom is unknown, but
because preeclampsia is associated with severe retinal
vasospasm, 1 it is likely that ischemia plays a role. However, there are no published data acquired from a
patient during an episode of visual disturbance to

From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine.
Received for publication March 2, 1993; revised April 20, 1993;
accepted May 6, 1993.
Reprint requests: Michael A. Belfort, MD, Division ofMaternal-Fetal
Medicine, Department of Obstetrics and Gynecology, One Baylor
Flaw, Houstin, TX 77030.
Copyright 1993 by Mosby-Year Book, 1nc.
0002-9378/93 $1.00 + .20 6/1/48451

support this theory. We report a case in which the

orbital arterial supply was assessed with color flow
Doppler ultrasonography during and after an episode
of visual disturbance in a patient with imminent eclampsia.

Case report
A 28-year-old Hispanic woman, gravida 3, para 2, was
admitted to the Ben Taub Hospital at 36 weeks' gestation with a blood pressure of 181/93 mm Hg and
proteinuria (2 + ). There was no history of chronic renal
disease or chronic hypertension, and her prenatal
course had been otherwise uneventful. A diagnosis of
preeclampsia was made. The patient complained of a
severe headache on admission and soon afterward reported visual disturbances characterized by flashes of
bright light in both eyes. Color flow Doppler examina-

523