© Georg Thieme Verlag KG Stuttgart · New York
Implantation of an esophageal squamous cell carcinoma at the site of a percutaneous endoscopic gastrostomy
24 October 2007 (online)
A 54-year-old man presented with a stenosing, moderately differentiated squamous cell carcinoma (SCC) of the proximal esophagus. Tumor stage was cT3-4N1M0. The patient underwent radiochemotherapy with curative intent. A percutaneous endoscopic gastrostomy (PEG) was placed using the standard pull-through method.
After 5 months the patient noticed a skin alteration at the site of the PEG, which was regarded as granulation tissue ([Fig. 1]). In a routine gastroscopy 2 months later, an ulcer at the gastric site of the PEG was found ([Fig. 2]), and initially diagnosed as adenocarcinoma. Computed tomography demonstrated a tumor mass along the PEG-tube ([Fig. 3]). Additionally, a suspicious hypodense hepatic lesion was detected. Complete local esophageal tumor control was documented. At laparotomy, a frozen section of the liver lesion showed a poorly differentiated SCC. Therefore, palliative subtotal gastrectomy with en bloc resection of the abdominal wall was carried out ([Fig. 4]).
Fig. 1 Macroscopic aspect showing the skin alteration at the site of the PEG, which was regarded as granulation tissue.
Fig. 2 Gastroscopic view of the tumor at the PEG site.
Fig. 3 Metastatic tumor implantation at the site of the PEG; the tumor mass extends from the gastric lumen to the skin.
Fig. 4 Esophageal squamous cell carcinoma with distinctive lymphangiosis and hemangiosis carcinomatosa (H & E staining).
Since the first description of PEG in 1980 , it has become a valuable method for nutritional support. The implantation of oropharyngeal or esophageal cancer at PEG stoma sites is a rare complication with an unknown incidence . The average period of time from tube placement to metastatic spread is reported to be approximately 9 months (range 3 - 18 months) . Length of survival following this complication is rarely reported, and varies between 2 and 28 months . The mechanism of tumor spread to the PEG site is controversial. Hematogenous or lymphatic spread to a susceptible site, as well as - more likely - direct mechanical implantation at the time of the PEG placement are proposed   . To avoid mechanical tumor implantation, the contact of the PEG tube with the tumor should be minimized. In patients with bulky, stenosing tumors this can be achieved by using a sheath or overtube. Alternatively, radiologic or operative placements can be carried out.
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M. Fein, MD
Department of Surgery
Zentrum Operative Medizin (ZOM)
Oberduerrbacher Strasse 6
D - 97080 Wuerzburg