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Tumor Discovery Surgical implantation of malignant cells

patients developed skin recurrences in the neck during multivariate analysis. Probably, the frequency at which
follow-up. The presence of cancer cells in washings from these shed tumor cells result in perioperative metastasis is
the surgeon’s gloves and instruments has been documented difficult to measure .
[32]
by Curran et al. . These findings and observations are
[20]
clear indications that exfoliated cancer cells are present 4.6. Port site metastasis
in wound washings, drainage fluid, and washings from The first case of port site metastasis was reported in a patient
surgical gloves and instruments and can implant in the cut of malignant ovarian ascites and since then whether
[33]
surfaces and wounds, thereby causing local and cutaneous the laparoscopic procedure or the physical effect of the
failures. However, none of the previous studies have been procedure triggered the metastasis has been a subject of
able to detect a statistically significant association between debate. It has been reported following laparoscopic resection
positive smears and local and distant failures. of gallbladder, ovarian, gastric, lung, colonic, and other

Many animal experiments have been conducted to malignancies but the greatest number have occurred after
[25]
explore methods to prevent the implantation of cancer colonic resection (<35) . Port site metastasis in colorectal
cells. In each experiment, an aggressively growing tumor cancers have been studied in much greater detail than
strain was used, and about 10,000 – 5,000,000 cells were cancers of other sites. It has been found that over a 2-year
required for successful implantation in small animals [21-24] period the incidence of port site metastasis varies from
while 10 – 10 cells in porcine models . These figures 0 – 2.3% [25,34] . Two reviews [34,35] list tumor cell spillage, tumor
[25]
6
7
have been corroborated by different researchers [9,10] . Studies aggressiveness (stage and grade), and pneumoperitoneum
designed to enumerate the viable cells in these washings as the possible risk factors. Quantitative measurements
are hitherto unavailable. To quote Dr. George E. Moore , of residual cancer cells after robotic-assisted radical
[22]
“… if you have a patient with far-advanced carcinoma of the cystectomy revealed that cancer cells can be found in most
stomach and inoculate him with cells from his own cancer, pelvic washes and a majority of these patients developed
[36]
subcutaneously, they will grow only 10 – 15% of the time.” recurrence within 2 – 16 months . A meta-analysis of
1182 subjects demonstrated that the presence of both pre-
4.5. Abdominal and peritoneal implantation resection and post-resection tumor cells increased the odds
[37]
In 1952, on the findings of 10.9% recurrence in suture ratio of local and overall recurrence . An investigation
lines in 55 patients of colorectal cancer, Cole reasoned into the effect of carbon dioxide pneumoperitoneum in
[26]
that (i) based on previous evidence, colorectal cancer T cell immune-deficient nude mice model revealed no
[38]
is susceptible to proximal, rather than distal, lymphatic difference in intraperitoneal implantation as compared
spread; (ii) surgeons remove about 5 centimeters of to gasless laparoscopy. In another experiment comparing
bowel proximally and distally so they do not go through pneumoperitoneum, gasless laparoscopy, and laparotomy,
the tumor; and (iii) recurrences were found only on end- the authors found significant differences in total tumor load
to-end anastomosis and not if a proximal segment end and growths at omentum and scrotal fat in mice subjected to
[39]
colostomy has been performed; given these reasonings, the carbon dioxide pneumoperitoneum . These contradictory
recurrence must have been caused by the implantation of results point to the fact that there is no consensus on the
malignant cells originating in the colonic lumen. Fortner etiology of port site recurrence.
et al. recorded recurrent tumors in the abdominal wall in Many other theories have been advanced to explain
1.9% of gastric carcinomas . The viability of these tumor port site metastasis, including “chimney effect” due to
[6]
cells and their ability to leak through an anastomosis and leakage of gas along trocars , aerosolization of tumor
[40]
cause local recurrence has been documented in 1984 cells, and direct contamination of trocar site by surgical
[27]
and 1989 . A study on exfoliated cells implanted on instruments . Often, port site recurrence is detected
[24]
[41]
rats has shown that the cell growth occurred on damaged at the site of specimen retrieval due to tumor spillage .
[42]
mucosa but the intact mucosa was completely resistant Morcellation of the specimen can also cause intraperitoneal
to implantation . The presence of free peritoneal tumor dissemination of cancer . In their review on the etiology
[43]
[28]
cells has a positive predictive value of 91% and specificity of port site recurrences, Whelan and Lee opined that poor
[29]
of 97% for tumor recurrence. A systematic review on free surgical technique leading to traumatization of the tumor
intraperitoneal tumor cells concluded that their presence is the principal cause of the release of substantial number
[30]
was a negative prognostic factor in colorectal cancers . of cells, which is a prerequisite to port site recurrence.
[31]
Howver, results of the recent EVOCAPE 2 multicenter As the surgeon gains experience in laparoscopic surgery,
prospective study showed that although 2-year survival his tumor handling improves, decreasing the number of
was significantly lower in patients with intraperitoneal exfoliated malignant cells and the incidence of port site
cancer cells, it was not an independent predictor on recurrences. The rate of port site recurrences now drops
Volume 2 Issue 3 (2023) 5 https://doi.org/10.36922/td.1411