Use of wire guided localization for resection of recurrent, oligometastatic gynecologic clear cell carcinoma to anterior abdominal wall.

After appropriate discussion and consent, the patient was taken for CT imaging and radiologic placement of the localizing wire. ( Fig. 1 ) The wire was placed in the center of the abdominal wall nodule and the patient was then transferred to the operating room for surgery. ( Fig. 2 ) A vertical incision on the anterior abdominal wall above and below the wire tract at the level of the mass was made. After reaching the subcutaneous layer, an elliptical incision was made around the wire with a minimum distance of 3 cm from the wire through subcutaneous fat, abdominal wall muscles, fascia, and peritoneum. ( Fig. 3 ) The entire localized lesion, including abdominal wall fascia and the palpably normal surrounding adipose tissue, were widely resected using electro-cautery. The specimen removed measured 9.0x8.5x6.5 cm. An 8.0x4.0 cm biological mesh was placed to aid in abdominal wall closure. The final pathology report showed clear-cell carcinoma consistent with gynecologic origin measuring 1.5 cm. The margins were free of tumor, with the closest margin being 7 mm. Post-operatively, the patient recovered uneventfully and suffered no associated wound complications. No adjuvant therapy was added. As of this writing she remains clinically and radiographically without evidence of disease with a recurrence free interval of greater than 4 years. Fig. 1 CT guided placement of localization wire. Fig. 2 Preoperative wire in abdominal wall. Fig. 3 Three-centimeter elliptical incision surrounding wire (black arrow). CT guided placement of localization wire. Preoperative wire in abdominal wall. Three-centimeter elliptical incision surrounding wire (black arrow).

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. Hayley Womack: Data curation, Writing – review & editing. Fadi Abu Shahin: Conceptualization, Methodology, Data curation, Writing – original draft. Edward Grendys: Conceptualization, Methodology, Data curation, Writing – review & editing.

Wire localization techniques have been described and used extensively for preoperative marking of nonpalpable breast lesions to facilitate the identification and complete resection of these lesions through small incisions. ( Franceschini et al. ) It has also been used to localize axillary sentinel lymph nodes or radiologically suspicious lymph nodes as part of the surgical management of breast cancer ( Caudle et al., 2015 ). The second most common reported use is the wire localization of small lung nodules to facilitate excision through a VATS procedures ( Park et al., 2017 , Chao et al., 2006 ). A scoping literature review was performed using search terminology such as “wire-guided localization”, “computer tomography-guided”, “ultrasound-guided”, “cancer”, “malignancy”, “resection margins” and “gynecology.” Results from our search suggests that this is the first reported case of using wire localization to facilitate precise and complete resection of oligometastatic recurrent gynecologic cancer ( Mihailovici et al., 2017 ). This case suggests a unique application of a previously described technique which allowed for an optimal surgical approach with limited resultant morbidity. We suggest that this similar approach may be applicable in other clinically difficult, non-palpable, locoregional recurrent disease and may facilitate resection with improved rates of lesion identification including intramuscular, subcutaneous, hepatic and possibly cranial or spinal disease ( Quinn et al., 2001 , Rutten et al., 1997 , Rodrigues et al., 1999 , Chang et al., 2017 , Thompson et al., 2017 , Thomas et al., 2011 , Kasugai et al., 1993 , Slotty et al., 2010 ).

The authors have no financial conflicts of interest to disclose.

Clear cell carcinoma arising from probable endometriotic implants within a cesarean section scar is rare, with only a few cases reported in current literature ( Mihailovici et al., 2017 ). Primary therapies include radical resection of the abdominal wall disease, which is usually accompanied by total hysterectomy, bilateral salpingo-oophorectomy and intrabdominal surgical cytoreduction. Adjuvant cytotoxic therapies commonly include platinum-based chemotherapy, most often combined with taxanes. Chemo-resistant clear cell recurrences occur frequently and are usually fatal. However, isolated recurrences can have favorable locoregional response when treated with localized radiotherapy. Apparent local disease recurrences have also been treated with surgical resection in attempts to obtain negative margins. Radical resection of abdominal wall disease can be technically challenging, particularly in populations that are heavily pretreated with prior surgeries and/or radiation therapy. Difficulty can arise in identification of disease due to presence of dense fibrotic tissue, which arises from prior interventions. In pretreated populations, morbidity is high with complications such as wound disruption, infection, and subsequent hernia formation ( Horvath et al., 2013 ). Furthermore, complex abdominal wall reconstruction including fascial release and use of mesh are often necessary and associated with significant post-operative complications. Thus, there exists a space for creative repurposing of commonly used techniques to better treat this complex population in efforts to achieve more favorable outcomes. Image guided wire localization is a widely recognized method to help identify surgical sites of interest, improve accuracy of resection, and lessen the need for excessive removal of normal tissue. It is for these very reasons that this method has become the standard of care in modern breast surgery. Wire guided localization results in significantly less anatomical disfiguration and decreased post operative morbidity. ( Franceschini et al. ).

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.