Laparoscopic Resection of An Extragastrointestinal Stromal Tumor in the Presacral Area

Abstract

Study objective: To show a surgical video in which a retroperitoneal extragastrointestinal stromal tumor was resected with the laparoscopic approach in the presacral area.

Design: A case report (Canadian Task Force classification III). The local ethics committee waived the requirement for approval.

Setting: A very small proportion of extragastrointestinal stromal tumors (EGISTs) is located in the retroperitoneal region. There are insufficient data on the clinical and pathologic features and the long-term follow-up of these tumors [1]. There are a few cases reported in the presacral region in the literature. The gold standard treatment for EGISTs is complete surgical excision of the mass. If it is possible, en bloc excision with its surrounding tissue is very important [2].

Patient: A 53-year-old woman. The patient provided informed consent to use images and videos of the procedure.

Interventions: This is a step-by-step illustration for resection of a retroperitoneal EGIST in the presacral area. The patient was a 53-year-old, gravida 3, para 3 white woman. She presented with abdominal pain for 5 months. Magnetic resonance imaging showed a 4-cm diameter solid mass localized at the presacral area. Laboratory test results for tumor biomarkers were as follows: cancer antigen (CA) 125 = 40 U/mL (normal values <35 U/mL), CA 19-9 = 29 U/mL (normal values <37 U/mL), carcinoembryonic antigen = 2.1 ng/mL (normal values <3 ng/mL), and CA 15.3 = 18 U/mL (normal values <35 U/mL). Because of malignancy suspicion, gastroscopy and colonoscopy were performed and revealed no abnormality. The Papanicolaou smear and endometrial biopsy results were negative. After preparation of the patient, laparoscopy was performed. After placement of an 11-mm umbilical port and three 5-mm abdominal ports, the pelvis and abdomen were explored and revealed a 4-cm retroperitoneal mass in the presacral area. The peritoneum overlying the presacral mass was incised and the retroperitoneum explored. Given the proximity to the mass, left ureterolysis was performed. The mass was located on the left internal iliac vein and dissected carefully. The retroperitoneal attachments were resected, and the presacral mass was removed without any complications. In order not to widen the abdominal incisions, a posterior colpotomy was performed in the cul-de-sac at equal distances from the uterosacral ligaments. An Endobag (Covidien, Dublin, Ireland) was introduced through the 5-mm port site at the posterior colpotomy. The specimen was removed in the Endobag through posterior colpotomy.

Measurements and main results: The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 2. Pathology revealed a 4-cm retroperitoneal EGIST with negative margins. Immunohistochemistry measurements revealed hematoxylin-eosin; CD117; S100 positivity; and CD34, CD68, desmin, and DOG1 negativity. The cell type was mixed (spindle and epithelioid type). The mitotic rate was 1 to 2/50 high-power fields. The patient has been disease free since the completion of surgery.

Conclusion: Laparoscopic complete resection of the retroperitoneal EGIST in the presacral area is successfully performed in this patient. The patient presented by us is an example showing that minimally invasive procedures can be used in the treatment of this type of tumor in the presacral area. The key point in this operation is to control the relationship of vascular structures and a ureter with a tumor in every step to avoid any injury.

Keywords: Extragastrointestinal stromal tumor; Laparoscopy; Presacral mass.