Clear Cell Carcinoma of the Abdominal Wall as a Rare Complication of General Obstetric and Gynecologic Surgeries: 15 Years of Experience at a Large Academic Institution

Abstract

The objective of this article was to report the clinicopathological characteristics, treatment modalities, and outcomes of patients with clear cell carcinoma (CCC) of the abdominal wall. Medical records of six patients diagnosed with CCC of the abdominal wall between May 2003 and May 2018 at the National Taiwan University Hospital were reviewed. All patients had prior obstetric or gynecologic surgeries. The primary clinical presentation was enlarging abdominal masses at previous surgical scars. Four patients underwent initial/primary surgeries with/without adjuvant chemotherapy. One patient received neoadjuvant chemotherapy followed by surgical intervention and adjuvant chemotherapy, the other received chemotherapy and sequential radiotherapy without any surgical intervention. Two of four patients undergoing initial/primary surgeries had disease recurrence and the remaining two cases without initial surgery experienced disease progression during primary treatment. Inguinal lymph nodes were the most frequent sites of recurrence. In conclusion, previous obstetric or gynecologic surgery can be a risk factor for CCC of the abdominal wall. Complete resection of abdominal wall tumor and suspected intra-abdominal lesions with hysterectomy and bilateral inguinal lymph nodes dissection may be the primary treatment. Adjuvant chemotherapy would be considered for potential benefits. For patients without bilateral inguinal lymph nodes dissection, careful inguinal lymph node palpation during postoperative surveillance is necessary. More cases are still needed to elucidate the clinical management of this disease.

Keywords: abdominal wall; cesarean section; clear cell carcinoma; endometriosis; inguinal lymph node; malignant transformation.

Figure 1

Representative gross, histology, and preoperative computed tomography (CT) scan of clear cell carcinoma of the abdominal wall. (A) A 17.5 cm mass lesion in the lower abdomen with an ulcerative surface (case 1). (B) Pathologic examination of the abdominal wall tumor showed tubulocystic growth patterns lined by cuboidal, hobnail cells, and clear cells. Focal papillary, micropapillary, and cribriform patterns were also present (case 4, H&E stain, 200X). (C) Granuloma caused by suture material was noted in the tumor sample (case 4, H&E stain, 40X). (D) A 13.0 cm lobulated heterogeneous tumor (star) was located at the anterior lower abdominal wall with peritoneal involvement (arrows) (case 4). (E) No definite lesions in the uterus, ovaries, and fallopian tubes were noted (case 4). (F) Lymphadenopathy along the right inferior epigastric vessels and external iliac vessels was noted (arrow) (case 2).

Figure 2

Representative image studies of recurrent tumors. (A) CT scan showed a 2.0 cm enlarged lymphadenopathy (arrow) in the left inguinal area (case 2). (B) Whole body bone scan demonstrated hot areas at the thoracic and lumbar spine (arrows) (case 1). (C) CT scan showed a 4.0 cm necrotic mass suggesting metastases at the left neck area (star) (case 5). (D) CT scan showed a 6.0 cm tumor at the lateral and medial segments of the liver (star) (case 5). (E) CT scan exhibited a 0.7 cm pulmonary nodule at the superior segment of the right lower lobe (arrow) (case 5).

Figure 3

Flowchart of management for patients with clear cell carcinoma (CCC) of abdominal wall. Note: CCC, clear cell carcinoma; NACT: neoadjuvant chemotherapy; C/T: chemotherapy; R/T: radiotherapy.