Title: The minimally invasive resection of port-site metastasis of ovarian cancer after
laparoscopy with cutaneous integrity: a case report and literature review
Version: 2 Date: 10 Aug 2024
Reviewer:  Phuc Nhon Nguyen
Reviewer's report:
Dear authors,
Thank you for your interesting case about port-site metastasis (PSM) after ovarian cancer
resection. In this report, the authors concerned minimally invasive surgical method in terms of
cutaneous integrity, wound healing, postoperative pain, enhance recovery time, decrease tumor
load, and potentially lower the chemotherapy and/or radiotherapy dose. However, the authors
should expand the practical points:
- PSM after laparoscopy for ovarian cancer has been documented by Childers JM et al (1994).
PSM also has been documented in other malignancies.  Benabou K, Khadraoui W, Khader
T, et al. Port-Site Metastasis in Gynecological Malignancies. JSLS. 2021;25(1):e2020.00081.
doi:10.4293/JSLS.2020.00081
- The hypotheses of PSM pathogenesis involving the immune response, pneumoperitoneum,
wound contamination, and surgical method should be discussed. Hyperthermic CO2 insufflation
and humidified CO2 insufflation can serve as promising adjuvant treatment for preventing PSM
development.
+Gao Q, Guo L, Wang B. The Pathogenesis and Prevention of Port-Site Metastasis in
Gynecologic Oncology. Cancer Manag Res. 2020;12:9655-9663. Published 2020 Oct 6.
doi:10.2147/CMAR.S270881
+Port-site metastasis in laparoscopic gynecological oncology surgery: An overview by Vahan
et al. https://doi.org/10.1016/j.gmit.2015.06.009
-The survival outcomes are equal in  laparoscopy and laparotomy. Kong, Q., Wei, H., Zhang,
J. et al. Comparison of the survival outcomes of laparoscopy versus laparotomy in treatment of
early-stage ovarian cancer: a systematic review and meta-analysis. J Ovarian Res 14, 45 (2021).
https://doi.org/10.1186/s13048-021-00793-1. How about the risk of PSM between laparoscopic
and laparotomic intervention. Which surgical intervention has a higher rate of PSM in the same
stage of ovarian cancer which the patient underwent either laparoscopy and laparotomy?
-The PSM regarding resection of ovarian cancer has been reported recently. The authors should
compare the advantage of 2 methods (laparoscopic/laparotomic resection) in safety. Since I
concern about the risk of recurrence between 2 reports.  Yu N, Zhou T, Sun H, Fu P, Liu R.
Port Site Metastasis After Minimally Invasive Surgery in Gynecologic Malignancies: Two Case
Reports and a Review of the Literature. Int J Womens Health. 2023;15:579-588. Published 2023
Apr 12. doi:10.2147/IJWH.S406488.
-The authors did not mention the suitable size for laparoscopic method? I recommend the
surgical methods should be individualized based on patient’s age, concomitant disease (diabetes,
coagulopathy), and cosmetic desire of the patient?
-How to reduce the risks of dissemination of malignant cells during procedure? Does it relate
to the types of ovarian cancer?
-How the detection of PSM could be early diagnosed? The mass size of tumors were 5 and 10
cm. It seems likely a late detection. A message relating to strict monitoring the abnormality at
port-site after laparoscopy should be given.
-The role of doppler ultrasound in gynecologic field should be added. Nguyen PN, Nguyen
VT. Additional value of Doppler ultrasound to B-mode ultrasound in assessing for uterine
intracavitary pathologies among perimenopausal and postmenopausal bleeding women: a
multicentre prospective observational study in Vietnam. J Ultrasound. 2023;26(2):459-469.
doi:10.1007/s40477-022-00732-w.
In this case, the ultrasound should be used as a modality imaging besides the clinical check-up
for early diagnosis of PSM.
Some other comments:
-Case presentation in abstract should be expanded.
-Parity, gravida, and concomitant disease should be added in presentation case.
-The authors should mention if the patient underwent a history of hysterectomy previously.
-Intraoperative blood loss should be given.
-Did the team use the laparoscopic bag to collect the specimen and avoid the spread of malignant
tissue?
-Antibiotic treatment was applied or not?
-Radiotherapy and chemotherapy after surgery should be described in detail in this patient.
-Please add the summary table of PSM cases following ovarian cancer resection in the last-10
year.
-In Figure 4, please use circle shape instead of hand-drawling to increase the quality of images.
-Photos demonstrating the histopathological examination should be provided.
-The long-term follow-up should be noted.
-References should be updated.
-English editing is required.
Best regards,