minimally invasive gynecologic surgery ( migs ) for gynecologic malignancies was initially challenged regarding safety and efficacy .
discussions of port - site metastasis ( psm ) questioned whether surgeon technical skill , port - site tumor extraction , local surgical seeding of port - sites , or pneumoperitoneum contributed to psms ( curet , 2004 ) .
the lap2 trial reported a 0.24% ( 4/1696 ) psm incidence ( walker et al .
while uncommon , psm remains troubling as some experts consider psm indicative of advanced disease and poor prognosis ( zivanovic et al .
many psms are present in the setting of disseminated disease ( zivanovic et al . , 2008 ,
national comprehensive cancer network guidelines recommend surgical excision of resectable , isolated metastases and consideration of adjuvant chemotherapy or radiation therapy ( national comprehensive cancer network , 2014 ) .
therefore , administration of radiation or chemotherapy after surgical treatment of an isolated psm is currently individualized based on expert opinion .
here we present an unusual case of a clinically isolated psm diagnosed after a long 40  month disease free interval following migs staging of an early stage uterine carcinosarcoma .
ten months after management of the initial isolated psm , the patient developed obvious disseminated disease .
increased reporting of outcomes associated with clinically isolated psm may influence post - resection management by increasing utilization of systemic chemotherapy to treat suspected underlying disseminated disease .
a 71  year old woman with body mass index of 21  kg / m was presented with post - menopausal uterine bleeding and underwent endometrial biopsy , which revealed a high - grade endometrial serous adenocarcinoma . computed tomography of the abdomen and pelvis demonstrated a 3.5  cm uterine mass , and was without evidence of lymphadenopathy , ascites , or metastasis .
robotic - assisted total laparoscopic hysterectomy , bilateral salpingo - oophorectomy , pelvic and para - aortic lymph node dissection , and infracolic omentectomy was performed without complication .
five abdominal incisions were made for the robotic camera and instruments , as well as an accessory port .
electrocautery bilateral tubal ligation was first performed to prevent retrograde cancer cell spillage into the peritoneum .
port sites were closed using a gore suture passer and the skin was closed with 40 vicryl .
pathologic diagnosis was stage ii uterine carcinosarcoma with components of serous adenocarcinoma , endometrioid adenocarcinoma , undifferentiated carcinoma , and undifferentiated spindle cell sarcoma .
the tumor was 2.5  cm in maximum dimension in the uterine fundus with maximum depth of invasion of 15% of total myometrial thickness and had superficial cervical stromal invasion .
she received adjuvant high - dose - rate vaginal cuff brachytherapy ( 2100  cgy total dose in 3 weekly fractions ) between six cycles of paclitaxel ( 135  mg / m ) and ifosfamide ( 1.6  g / m ) every three weeks , with three cycles of chemotherapy administered before brachytherapy and an additional three cycles after brachytherapy .
she remained without evidence of disease for 40  months , when she presented with a subcutaneous mass on the right lower quadrant at the location of a previous port - site . computed tomography of the abdomen and pelvis demonstrated a 3.5  cm heterogeneous mass in the deep subcutaneous tissues of the right lower quadrant and was without evidence of other disease ( fig .
she underwent surgical resection of the mass , which extended to the fascia but not the peritoneum , which was not entered .
pathology confirmed metastasis ( high grade adenocarcinoma ) consistent with her previous uterine primary ( fig .
she received external beam radiotherapy of 5990  cgy total dose to the right lower quadrant recurrence site .
five months later , she had a new palpable lump at the right flank , 3  cm superior to the previous mass .
positron emission tomography ( pet / ct ) was performed and revealed a solitary focus of activity in the superficial right abdominal wall distinct from the previous recurrence site ( fig .
the mass was resected with clean margins and pathology again confirmed metastasis consistent with the primary diagnosis . in the presence of severe back pain
, she underwent another pet / ct two months after resection , which revealed new pulmonary nodules concerning for metastasis and l4 vertebral metastasis .
she began palliative oral etoposide ( 50  mg alternating with 100  mg for days 121 , then 7  days off , every 28  days ) chemotherapy .
many hypotheses have been proposed to explain the development of psm including direct wound seeding by specimen removal or contaminated instruments , aerosolization of exfoliated cancer cells , the  chimney effect  caused by insufflation , and pneumoperitoneum , carbon dioxide , or tissue trauma altering the normal immunologic defenses at port sites ( curet , 2004 ) .
there is little evidence to support any practice to reduce psm risk ( curet , 2004 ) .
the lap2 trial reported a low psm incidence of 0.24% , which is acceptable compared to laparotomy ( walker et al .
, 2012 , gcer et al . , 2005 ) . furthermore , the lap2 trial concluded that the use of mis was safe regardless of pathological subtype ( walker et al . , 2012 ) .
reviewed published data of psm after staging for endometrial cancer ( palomba et al . , 2012 ) .
isolated psm were all endometrioid histology , high grade , and stage i or ii at initial diagnosis .
one patient declined excision and underwent palliative radiation plus hormone therapy before succumbing to disease 5  months later .
one patient had excision followed by radiation and was disease free for 30  months before recurring and dying of disease 42  months after first recurrence .
also concluded that apparently isolated psm may represent occult , disseminated metastatic disease ( palomba et al . , 2012 ) .
carlson et al . reported an interesting psm at a right upper quadrant ( ruq ) port - site used for laparoscopic cholecystectomy that was performed 6  months prior to the patient 's staging and diagnosis of stage iiic serous ovarian cancer ( carlson et al . , 2002 ) .
twenty - seven months after laparoscopic surgical staging and cytoreduction of the ovarian malignancy , she developed a psm at a ruq port - site from her prior laparoscopic cholecystectomy .
six months later she developed a pelvic recurrence and was treated with additional platinum chemotherapy .
she subsequently remained disease free for three years prior to the report of her case .
the apparently isolated ruq psm also preceded the development of additional metastatic disease despite treatment of the psm with resection and systemic chemotherapy .
uterine carcinosarcoma , although initially considered to be a sarcoma , is now recognized as an advanced carcinoma that undergoes an epithelial - to - mesenchymal transformation ( cantrell et al . ,
it is one of the most aggressive types of uterine pathologies , associated with high recurrence rates and a 5-year survival of 3339% ( cantrell et al . , 2015 ) .
in our case , the patient developed an isolated uterine carcinosarcoma psm after a 40  month disease free interval but before any indication of systemic disease .
later , she developed an additional abdominal wall metastasis , as well as suspected pulmonary and bone metastases .
we propose that when patients develop an apparently isolated psm , although additional metastases may not yet be evident by imaging , the presence of psm indicates high risk for progression of disease and warrants systemic treatment in additional to local excision and/or radiation . we propose that patients with apparently isolated psm without evidence of other metastatic disease require systemic chemotherapy in addition to excision and/or radiation therapy to the site of recurrence .
psm of carcinosarcoma indicates a poor prognostic condition for the patient and palliative discussions should be initiated .
case reports , case series and literature reviews informing expert opinion will likely remain the highest level of evidence for the clinical dilemma of isolated psm .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .
 a 71-year - old woman with suspected endometrial cancer underwent robotic - assisted hysterectomy , bilateral salpingo - oophorectomy , pelvic and para - aortic lymph node dissection , and infracolic omentectomy revealing a stage ii uterine carcinosarcoma with components of serous adenocarcinoma and undifferentiated spindle cell sarcoma . 
 there was no evidence of distant metastasis at the time of surgery . 
 however pelvic washings were positive for malignant cells . 
 she received adjuvant chemotherapy and vaginal cuff brachytherapy . 
 forty months later she developed a subcutaneous mass at the location of previous port site which was confirmed to be recurrence of the uterine primary . 
 she subsequently developed additional distant metastases to the abdominal wall , lungs , and bone . 
 port site metastasis ( psm ) was the earliest indicator of disseminated metastatic disease in this patient . 
 we review challenges in the management of patients with psm and propose that psm be considered as a sign of systemic disease even when presenting as an apparently isolated recurrence . 
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