|Year : 2018 | Volume
| Issue : 3 | Page : 247-249
Port site desmoid tumour following laparoscopic cholecystectomy: A case report
Gautham Krishnamurthy, Vijay Chetan Jha, Ganga Ram Verma
Department of General Surgery, Division of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||21-Oct-2017|
|Date of Acceptance||04-Nov-2017|
|Date of Web Publication||6-Jun-2018|
Prof. Ganga Ram Verma
Department of General Surgery, Division of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Desmoid tumours are locally aggressive tumours occurring either spontaneously or in familial conditions. History of trauma is invariably present with surgical trauma being a common cause. Port site desmoid tumours are extremely rare conditions. Inadequate treatment results in high recurrence rate and substantial morbidity. Reconstruction, if required, by the appropriate technique is vital to avoid an incisional hernia. Adjuvant therapy may be useful in large locally advanced or recurrent tumours. We describe a young female with large port site desmoid tumour following laparoscopic cholecystectomy managed with wide local excision and mesh placement.
Keywords: Laparoscopic cholecystectomy, mesh repair, port-site desmoid, wide local excision
|How to cite this article:|
Krishnamurthy G, Jha VC, Verma GR. Port site desmoid tumour following laparoscopic cholecystectomy: A case report. J Min Access Surg 2018;14:247-9
| ¤ Introduction|| |
Desmoid tumours are rare benign yet locally aggressive tumours of mesenchymal origin. It is characterised by abnormal proliferation of myofibroblast and accounts for 0.03% of all neoplasms. It has a female preponderance of reproductive age and known to develop following surgical trauma. The mechanism of their development is unknown and failure to recognise their malignant potential renders the desmoids tumours susceptible to inadequate treatment and high recurrence rate.
Development of desmoids at the port site following minimally access surgery is an extremely rare phenomenon. We present a case of a young female with a desmoid tumour in the abdominal wall at the anterior axillary port site following laparoscopic cholecystectomy. The rare occurrence of the tumour following laparoscopic cholecystectomy makes it an interesting association, and in view of its malignant potential, warrants awareness.
| ¤ Case Report|| |
A 34-year-old female presented with a gradually increasing painless parietal swelling over the right lumbar region for the past 2 years. She had noticed a rapid increase in size for the past 6 months. Abdominal examination revealed a firm, well-defined 10 cm × 8 cm lump arising from the anterior abdominal wall occupying right hypochondrium and the right lumbar region. Two months before the onset of the swelling, she underwent laparoscopic cholecystectomy. The right lumbar port site scar was found exactly over the summit of the lump. There was no family history of desmoid tumour. Contrast enhanced computed tomography (CECT) confirmed a homogenous mass of 9 cm × 7 cm × 10 cm arising from the right rectus abdominis muscle indenting the parietal peritoneum [Figure 1]a. Core needle biopsy confirmed the presence of spindle and stellate tumour cells embedded in the dense stroma, consistent with a desmoid tumour. The patient underwent wide local excision of abdominal wall muscles and parietal peritoneum. The defect was repaired with composite mesh and covered with native skin and subcutaneous tissue [Figure 1]b. She had an uneventful postoperative recovery.
|Figure 1: (a) Desmoid tumour (*) arising from the anterior abdominal wall abutting the peritoneum with no involvement of the underlying structures. (b) Intra-operative picture showing the composite mesh placed over omentum to cover the defect following the excision of the desmoid tumour|
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Histopathological examination revealed spindle- and stellate-shaped tumour cells embedded in dense fibrous stroma showing myxoid degeneration and focal hyalinisation suggestive of desmoid [Figure 2].
|Figure 2: (a) Gross Specimen and the (b) cut section of the tumour. (c) Spindle-shaped cells with dense stroma, suggestive of desmoid tumour (H and E, ×40)|
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She was started on tamoxifen 20 mg daily. At 20 months follow-up, the patient is doing well. There is no evidence of recurrence or an incisional hernia.
| ¤ Discussion|| |
Desmoid tumour develops from abnormal fibroblastic proliferation and characterised by abundant collagen surrounding poorly circumscribed bundles of elongated spindle-shaped cells. They are locally aggressive tumours and do not metastasise to distant organs. In general, most desmoids are slow growing, but 10% may progress rapidly as in the index case. The patient had noticed a rapid increase in size 6 months before her presentation.
Most of the tumours occur sporadically, but in 5% of cases, familial and association with familial adenomatous polyposis have been described. The mechanisms of the development and regulation of growth of desmoids tumours are unknown. Female sex hormones might be acting as a catalyst in the proliferation of fibroblasts as reflected by its tendency to develop in childbearing females, the possible role of anti-estrogenic drugs in management and the appearance of similar lesions in laboratory animals by administration of oestrogen.,
Previous history of trauma, often surgical in nature may trigger the development of desmoids in as high as 28% of cases. Wound healing and the fibroblastic proliferation takes place within 2 weeks of trauma. The resultant mesenchymal cellular proliferation may get dysregulated and acquire invasiveness from genetic or chance mutations, leading to aggressive fibromatosis also called desmoid. The present case is the fourth case of trocar site desmoids after laparoscopic surgery.,
The common sites of involvement include proximal extremities and abdominal wall. The tumour appears as homogenous soft-tissue mass of variable attenuation and enhancement on CECT. The imaging besides confirming the site of origin also helps in planning the extent of resection. Fine-needle aspiration has very poor specificity in diagnosing a desmoid tumour. Hence, core needle biopsy is the recommended for pre-operative tissue diagnosis. Histologically, these tumours appear benign in nature but may behave aggressively in their natural course.
Wide excision with negative margins remains the first-line of management in abdominal wall desmoid tumours. Abdominal wall reconstruction can be achieved with primary suturing, mesh repair or myocutaneous flap depending on the extent of the defect. Pedunculated desmoids projecting inside the abdomen can be excised by laparoscopic method  obviating the need of mesh or flap reconstruction. Hormonal therapy with tamoxifen or non-steroidal anti-inflammatory drugs has proved effective occasionally. Radiotherapy between 40 and 60 Gy has also been reported as an effective treatment with low toxicity in residual or recurrent tumours.
| ¤ Conclusion|| |
Trivial trauma from trocar may trigger uncontrolled fibroblastic proliferation leading to the development of desmoids in the anterior abdominal wall. CECT scan and core needle biopsy clinch the diagnosis. Wide excision with negative margins is the cornerstone in the management of abdominal wall desmoids. Large abdominal defect needs reconstruction with mesh to avoid an incisional hernia. Adjuvant treatment may be useful in large locally advanced or recurrent desmoids.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]