Gastric metastases of oral carcinoma resulting from percutaneous endoscopic gastrostomy placement via the introducer technique

Abstract

Introduction. Tumour cell implantation is a rare complication in patients with head and neck cancers, who have undergone percutaneous endoscopic gastrostomy (PEG) tube placement. It has not been reported in patients who underwent a PEG insertion via the radiological or introducer technique. We describe a novel case presentation of metastatic disease in a patient who underwent PEG placement via the introducer (Russell) technique which, to the best of our knowledge, has not not previously been described.Case presentation. The patient was a 37-year-old Malay woman who developed metastatic squamous cell carcinoma deposits in her stomach and liver one month after a gastrostomy tube was removed following the completion of treatment for oropharyngeal carcinoma.Conclusion. Previous authors have advocated the use of alternative PEG insertion technique apart from the ‘pull’ technique to minimise the risk of tumour implantation from head and neck cancers. Our case report suggests that this risk is not totally eliminated when the PEG tube is inserted via the introducer technique.

Head and neck cancer PEG site metastases: Association with PEG placement method

“…This hypothesis of direct tumor seeding appears reasonable when considering cases in which the period between PEG placement and diagnosis of metastasis to the PEG site is very short . However, cases of metastasis in patients in which a PEG was placed without instrument passage through the oral cavity or pharynx suggest alternate methods of tumor implantation . In fact, open gastrostomy and laparoscopic‐assisted gastrostomy tube insertion which both use entirely distinct surgical instruments to avoid tumor cross‐contamination, and result in greater expense, morbidity and recovery times, still have reported PEG site metastases, suggesting other mechanisms of seeding …”

“…73 However, cases of metastasis in patients in which a PEG was placed without instrument passage through the oral cavity or pharynx suggest alternate methods of tumor implantation. 12,16,38 In fact, open gastrostomy and laparoscopicassisted gastrostomy tube insertion which both use entirely distinct surgical instruments to avoid tumor cross-contamination, and result in greater expense, morbidity and recovery times, still have reported PEG site metastases, suggesting other mechanisms of seeding. 74 Regardless of the method used, the surgical placement of PEG tubes creates an environment potentially favorable for tumor implantation as the tumor cells have an increased likelihood of implanting in the incision site due to increased circulation to the site and its nutrient rich healing environment.…”

Tumor implantation following percutaneous endoscopic gastrostomy insertion for head and neck and oesophageal cancer: Review of the literature

“…Within the case reports, the vast majority of cases of seeding followed PEG insertion using the pull technique. One instance followed PEG insertion via a direct introducer technique . It is unclear what proportion of insertions was undertaken using other techniques.…”

“…One instance followed PEG insertion via a direct introducer technique. 39 It is unclear what proportion of insertions was undertaken using other techniques. Of the two cases identified in the postal survey, 70 one followed insertion using a push technique.…”

Radiology-guided percutaneous gastrostomy in patients with malignant dysphagia

“…Проведение эндоско-па при наличии опухоли в условиях компактной анатомии зачастую затруднено и требует определенных усилий. При этом зачастую происходит травма опухоли, что по всей видимости, может привести к контакту эндоскопа с ране-вой поверхностью сформированного канала гастростомы и его обсеменение [10,11].…”