Implantation metastasis after PEG: case report and review

Direct percutaneous endoscopic gastrostomy for nutritional support in patients with aerodigestive tract cancers

BACKGROUND

Conventional pull-through percutaneous endoscopic gastrostomy (PEG) risks infection and tumour implantation in head and neck cancers. Endoscopically inserted direct gastrostomy has lower rates of complications but is underutilised.

AIMS

To describe the endoscopic steps for direct gastrostomy insertion and review our single-centre experience to assess the technical feasibility and safety.

METHODS

Patients who underwent endoscopic direct gastrostomy insertion between December 2016 and June 2021 were included. A 24Fr introducer kit for gastrostomy feeding tube (Avanos Healthcare, Australia) was used. Patient and tumour characteristics, procedural data and 30-day outcomes were recorded.

RESULTS

Thirty patients underwent direct PEG insertion (mean age 64 years and 24 male). All were planned for or currently undergoing radiotherapy. Twenty-six (87%) of 30 cases were performed under conscious sedation over a median procedure time of 21 min (interquartile range 11 min). No tumour seeding was seen, and one case of PEG-site infection was observed.

CONCLUSIONS

Direct PEG is safe and effective and should be considered for patients with aerodigestive tract cancer in need of nutritional support.

Push versus pull gastrostomy in cancer patients: A single center retrospective analysis of complications and technical success rates

PURPOSE

To compare the technical success and complication rates of push versus pull gastrostomy tubes in cancer patients, and to examine their dependence on operator experience.

MATERIALS AND METHODS

A retrospective review was performed of 304 cancer patients (170 men, 134 women; mean age 60.3±12.6 [SD], range: 19-102 years) referred for primary gastrostomy tube placement, 88 (29%) of whom had a previously unsuccessful attempt at percutaneous endoscopic gastrostomy (PEG) placement. Analyzed variables included method of insertion (push versus pull), indication for gastrostomy, technical success, operator experience, and procedure-related complications within 30 days of placement.

RESULTS

Gastrostomy tubes were placed for feeding in 189 patients and palliative decompression in 115 patients. Technical success was 91%: 78% after endoscopy had previously been unsuccessful and 97% when excluding failures associated with prior endoscopy. In the first 30 days, there were 29 minor complications (17.2%) associated with push gastrostomies, and only 8 minor complications (7.5%) with pull gastrostomies (P<0.05). There was no significant difference in major complications (push gastrostomy 5.3%, pull gastrostomy 5.6%). For decompressive gastrostomy tubes, the pull technique resulted in lower rates of both minor and major complications. There was no difference in complications or technical success rates for more versus less experienced operators.

CONCLUSION

Pull gastrostomy tube placement had a lower rate of complications than push gastrostomy tube placement, especially when the indication was decompression. The technical success rate was high, even after a failed attempt at endoscopic placement. Both the rates of success and complications were independent of operator experience.

Disc-retained tubes for radiologically inserted gastrostomy (RIG): not up to the job?

AIM

To assess the insertion procedure and performance of disc-retained gastrostomy tubes, recording complications and accidental displacements by prospective audit, and to determine whether primary placement of the tube off-licence was feasible.

MATERIALS AND METHODS

Disc-retained 12 F single-lumen Monarch gastrostomy tubes (Enteral UK, Selby, UK) were inserted by three gastrointestinal interventional radiologists in a supra-regional cancer centre. The 12 F tubes required a 20 F peel-away sheath with four-point gastropexy fixation and were placed under conscious sedation, using electrocardiogram (EEG) bispectral index monitoring. Follow-up was performed in an in-house gastrostomy drop-in clinic at 1 week and 1 month, supplemented with weekly telephone follow-up. Patients also had open access to the gastrostomy drop-in clinic for immediate advice and complication management.

RESULTS

Eighteen patients underwent primary insertion of a Monarch gastrostomy tube over 5 months. A total of 6/18 (33%) tubes displaced; 4/18 (22%) completely, 2/18 (11%) occult into the peritoneum. Four of 18 (22%) patients developed infection at the stoma site. Due to the unexpectedly poor performance of the tube, the study was terminated early.

CONCLUSION

Initial experience with the Monarch disc-retained gastrostomy tube demonstrates it unsuitable for primary placement with current protocols. In view of the potentially serious complications, the Medicines and Healthcare Products Regulatory Agency (MHRA) has been informed. A request has been made to the distributer to reassess the tube design and/or review the procedure promoted for primary placement.

Metastasis of untreated head and neck cancer to percutaneous gastrostomy tube exit sites

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent.

METHODS

A comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases.

RESULTS

The literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months.

CONCLUSIONS

Metastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the "pull" technique of PEG placement may directly implant tumor cells at the gastrostomy site.

Metastatic Implantation of Head and Neck Squamous Cell Cancer at PEG Tube Site Exit— An Unusual Relapse Site: A Case Report and Review of Literature

Background

The placement of percutaneous endoscopic gastrostomy (PEG) tubes is a common procedure in patients with head and neck cancer who require adequate nutrition because of the inability to swallow before or after surgery and adjuvant therapies. A potential complication of percutaneous endoscopic gastrostomy tubes is the metastatic spread from the original head and neck tumor to the gastrostomy site.

Methods

This is a case of a 55-year-old male with a (cT4N3M0) stage IV squamous cell carcinoma of the oropharynx who underwent percutaneous endoscopic gastrostomy tube placement prior to commencement of definitive chemoradiation therapy and 7 months thereafter developed metastatic spread to the gastrostomy site. Tumor was treated with radiation therapy. A review of the published literature regarding the subject is done. The pull-through method of gastrostomy tube placement had been used in our patient as well as in the majority of the other cases reviewed in the literature.

Conclusions

There is a small but definite risk for tumor implantation in the gastrostomy site when using the pull technique in patients with active head and neck cancer. The direct implantation of tumor through instrumentation is the most likely explanation for metastasis; however, hematogenous seeding is also a possibility. Careful assessment of the oropharynx and hypopharynx before PEG tube placement and the use of alternative techniques for enteral access in patients with untreated or residual malignancy are recommended to minimize this risk.

Wound healing after trauma may predispose to lung cancer metastasis: review of potential mechanisms

Inflammatory oncotaxis, the phenomenon in which mechanically injured tissues are predisposed to cancer metastases, has been reported for a number of tumor types, but not previously for histologically proven lung cancer. We review clinical and experimental evidence and mechanisms that may underlie inflammatory oncotaxis, and provide illustrative examples of two patients with squamous cell carcinoma of the lung who developed distant, localized metastatic disease at sites of recent physical trauma. Trauma may predispose to metastasis through two distinct, but not mutually exclusive, mechanisms: (1) physical trauma induces tissue damage and local inflammation, creating a favorable environment that is permissive for seeding of metastatic cells from distant sites; and/or (2) micrometastatic foci are already present at the time of physical injury, and trauma initiates changes in the microenvironment that stimulate the proliferation of the metastatic cells. Further exploration of post-traumatic inflammatory oncotaxis may elucidate fundamental mechanisms of metastasis and could provide novel strategies to prevent cancer metastasis.

Percutaneous endoscopic gastrostomy site metastasis

Metastases to gastrostomy sites are a rare but significant complication of percutaneous endoscopic gastrotomy (PEG) placement in cancer patients. Both direct seeding and hematogenous spread have been suggested as possible mechanisms. This article outlines the incidence, presentation, pathogenesis, and management of PEG-site metastases.

Risk factors and risk reduction of malignant seeding of the percutaneous endoscopic gastrostomy track from pharyngoesophageal malignancy: a review of all 44 known reported cases

AIM

To comprehensively review all known reported cases of stomal metastases after percutaneous endoscopic gastrostomy (PEG) to systematically identify risk factors for this complication and to develop strategies for reducing this risk.

METHODS

Reported cases were identified by computerized literature searches. Criteria for risk factors for stomal metastases included: a substantially higher relative rate of this factor in patients with stomal metastases than expected from pharyngoesophageal malignancy in general, and biologic plausibility of this phenomenon.

LITERATURE REVIEW

Review of all 44 known stomal metastases revealed the following. The mean patient age was 59.0+/-10.0 (SD) yr, and 79% of patients were male. Pathologically proven stomal metastases were located in the abdominal wall (PEG exit site) in 63%, in the gastric wall (PEG entrance site) in 7%, and in both walls in 30%. Mean survival after diagnosis was only 4.3+/-3.8 months. Pathologic risk factors for stomal metastases included: (a) pharyngoesophageal location of primary cancer (in 100% of cases, 0% other locations); (b) squamous cell histology (in 98%, adenocarcinoma in 2%); (c) poorly or moderately differentiated histology (in 92%, well differentiated in 8%); (d) advanced pathologic stage (in 97%, early stage in 3%); and (e) large primary cancer size at diagnosis (mean diameter 4.2+/-2.3 cm). These risk factors appeared to be quantitatively large (e.g., 98% of cases had squamous histology vs 50% expected rate, odds ratio 40.1, OR CI 6.31-246.4, P<0.0001). Therapeutic risk factors for stomal metastases included: (a) endoscopic PEG placement (in 98%, surgical gastrostomy in 2%); (b) pull-string PEG technique (in 98%, push-guidewire in 2%, direct-introducer in 0%); (c) primary cancer untreated or known local recurrence after treatment before PEG (in 87%); and (d) time>or=3 months after PEG insertion (in 100%, <3 months in 0%; mean interval 7.8+/-5.2 months after PEG). Four of the currently reported risk factors are novel (pathologic factors d,e; therapeutic factors a,d).

CONCLUSIONS

Strong risk factors for stomal metastases include: pharyngoesophageal primary cancer, squamous cell histology, less well-differentiated cancer, large size, and advanced cancer stage. The risk may be reduced in patients with risk factors by radiotherapy, chemotherapy, or cancer surgery before PEG; by substituting the push-guidewire for the pull-string technique for PEG; and possibly by use of a sheath with the pull-string technique.

Endoscopic placement of enteral feeding catheters

PURPOSE OF REVIEW

Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present.

RECENT FINDINGS

Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement.

SUMMARY

Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.

SLiC technique

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has been an invaluable method for obtaining long-term enteral access and represents one of the first forays in the field of minimally invasive surgery. However, the traditional "pull" method for PEG tube placement continues to have some disadvantages, especially in patients with near-obstructive head and neck cancers.

METHODS

We describe a new "SLiC" technique for establishing percutaneous gastrostomy using a radially expandable trocar.

RESULTS

This technique is initially developed and refined on a porcine model and then successfully implemented on five human patients.

CONCLUSION

The SLiC technique can be done safely and efficiently with a pediatric-sized gastroscope and avoids the need for radiation from fluoroscopy. It is a good alternative for obtaining enteral access in patients who would otherwise not be well suited for a traditional PEG tube.

Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer

BACKGROUND

Abdominal wall metastasis after PEG tube placement has been reported in patients with head and neck cancer. The incidence of this occurrence is unknown.

OBJECTIVE

Evaluation of the incidence of abdominal wall metastasis as a complication of PEG tube placement in patients with head and neck cancer.

DESIGN

Retrospective chart review.

SETTING

H. Lee Moffitt Cancer Center and Research Institute, Nutritional Support Services.

SUBJECTS

Head and neck cancer patients requiring nutritional support with PEG tube placement.

RESULTS

Of the 304 patients with head and neck cancer, 218 had active disease with a viable tumor in the oropharynx or hypopharynx at the time of PEG placement. Two of these patients, both with active disease (0.92%), developed a PEG site metastasis.

CONCLUSION

There is a small but definite risk for tumor implantation in the gastrostomy site when using the pull technique in patients with active head and neck cancer. Careful assessment of the oropharynx and hypopharynx before PEG tube placement and the use of alternative techniques for enteral access in patients with untreated or residual malignancy are recommended to minimize this risk. Use of other percutaneous techniques that do not involve traversing the hypopharynx with the catheter may help to prevent tumor translocation. When head and neck cancers metastasize to the gastrostomy site, patient survival appears limited even with extensive resection.

Metastatic head and neck carcinoma to a percutaneous endoscopic gastrostomy site

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is a safe and widely accepted alternate route for enteral alimentation in the head and neck cancer patient population. Cancer metastatic to a PEG tube exit site is a rare but serious complication of this procedure. We sought to determine the route of spread responsible for PEG site metastases such that we may prevent further occurrences of this highly morbid condition. We also report a case of PEG site metastasis at our institution.

METHODS

We performed a MEDLINE search for the years 1962 to 2002 and conducted a review of the literature. In the case at our institution, a 63-year-old man was referred to our institution with recurrent squamous cell carcinoma of the right base of tongue; he also had a 1.5-cm left apical lung nodule. He underwent PEG tube placement at the time of staging panendoscopy. Six months after the original tube placement, he had an ulcerated mass develop at the PEG site; biopsy of the mass revealed squamous cell carcinoma histologically identical to the base of tongue tumor. He also had recurrent lung cancer and four hepatic lesions develop.

RESULTS

In our MEDLINE search, of the five patients diagnosed with PEG site disease >10 months after PEG placement, all five (100%) had synchronous distant metastatic disease. In the group of patients diagnosed with PEG site metastases < or =10 months after PEG placement, only four (24%) of 17 had synchronous distant metastatic disease. All patients underwent PEG placement by means of the "pull" technique. Direct implantation with a variable-sized initial tumor burden can explain all cases of PEG site metastasis. The presence of distant metastases is representative of the natural history of advanced head and neck malignancies. Smaller initial tumor implants present later than would larger initial tumor burdens, when the patient is more likely to have distant metastatic disease. In the case at our institution, the patient did not respond to treatment for his hepatic and PEG site metastases and his lung cancer, and he died 4 months after detection of the PEG site metastasis.

CONCLUSIONS

PEG site metastases are iatrogenic complications of PEG tube placement in patients with squamous cell carcinoma of the upper aerodigestive tract. The use of laparoscopic, open, or the "push" technique of PEG tube placement in patients with head and neck cancer may prevent direct implantation of malignant cells into an enteral access site.

Percutaneous endoscopic gastrostomy associated gastric metastasis

An interesting case of gastric metastasis of head and neck cancer after percutaneous endoscopic gastrostomy (PEG) placement is presented. Gastric metastases may appear in 3 morphologic varieties endoscopically. They may be multiple nodules of varying size, submucosal tumor masses with tip ulceration, or nonulcerated masses. Histologically, they may be seen as microscopic infiltration, a gross nodule, gross ulceration, or a gross hypertrophied wall. A case of PEG associated gastric metastasis has been reported almost every year since 1989. Even then, PEG placement by pull method continues to be a common procedure for patients diagnosed with head and neck cancer. The mechanism of gastric metastasis in patients with PEG is unclear. Seeding as well as hematogenous and lymphatic spread to traumatized tissue may be the cause.

Stomal metastases complicating percutaneous endoscopic gastrostomy: CT findings and the argument for radiologic tube placement

OBJECTIVE

This article describes the CT appearance of metastatic implantation at the percutaneous endoscopic gastrostomy (PEG) tract in patients with malignancy of the upper aerodigestive tract. Cumulative data from previous case reports are also considered for insight into causes of metastasis and the implications for gastrostomy placement in these patients.

CONCLUSION

CT showed lobulated soft tissue involving the entire abdominal wall PEG tract in all proven cases. CT is an effective method for evaluation because the tumor burden lies predominately in the abdominal wall and not at the entry or exit site. The stomal implant is often the only site of metastatic disease at presentation. In general, CT findings of mildly increased soft tissue along the PEG tract are nonspecific, but a lobulated mass is highly suspicious for tumor implantation, especially if the one-sided thickness exceeds 1 cm. The preponderance of evidence from the existing literature points to direct tumor implantation during endoscopic placement as the likely cause (rather than hematogenous spread). This conclusion would support the alternative of radiologic tube placement in these patients.

Metastasis of head and neck carcinoma to the site of percutaneous endoscopic gastrostomy: case report and literature review

BACKGROUND

Patients with head and neck cancer often need a percutaneous endoscopic gastrostomy to provide adequate nutrition because of inability to swallow after tumor radiation therapy. However, metastasis of the original tumor to the gastrostomy exit site may occur.

METHODS

We describe the case of a 61-year-old man with stage III (T2 N1) squamous cell carcinoma of the tongue in whom a PEG tube was placed to circumvent anticipated difficulties in swallowing after radiation therapy. We also compare this case with similar cases in the literature.

RESULTS

Soreness and erythema near the gastrostomy site reported by the patient were diagnosed as cellulitis, and two courses of antibiotic treatment were prescribed. However, a biopsy showed that the original squamous cell carcinoma had metastasized to the gastrostomy exit site. The "pull" method of tube placement had been used in this patient and in all 19 cases of metastasis reported in the literature.

CONCLUSIONS

Metastatic cancer should be considered in patients with head and neck cancer who have unexplained skin changes at the gastrostomy site. Our experience with this case and review of the literature indicate that, in patients with head and neck cancer, "pull" procedures for placement of gastrostomy tubes may induce metastasis by direct implantation of tumor cells because of contact between the gastrostomy tube and tumor cells. Methods of tube insertion that avoid such contact are preferred.

Cancer metastasis at percutaneous endoscopic gastrostomy stomata is related to the hematogenous or lymphatic spread of circulating tumor cells

Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive oropharyngeal and esophageal tumors. PEG tube placement is considered safe, and complications are infrequent. One complication, although rare, that is being increasingly reported is the metastasis of cancer at PEG stomata. Herein, a case of metastasis of an esophageal cancer at a PEG stoma is described. Although it has been previously suggested that cancer metastasis is due to direct seeding of the stoma, an analysis of the literature suggests that this phenomenon is related to the hematogenous or lymphatic spread of cancer cells to a susceptible site.