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 [1], 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
[2]. The average period of time from tube placement to metastatic spread is reported
to be approximately 9 months (range 3 - 18 months) [3]. Length of survival following this complication is rarely reported, and varies between
2 and 28 months [4]. 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 [3]
[4]
[5]. 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.
Endoscopy_UCTN_Code_CPL_1AH_2AI
