Stomal Metastases Complicating Percutaneous Endoscopic Gastrostomy: CT Findings and the Argument for Radiologic Tube Placement

Abstract

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.

Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results

“…Schrag [7] reported an incidence of less than 1% and Adelson [22] could only find 22 cases in a Medline search performed in 2004. Some authors recommend avoiding PEG insertion in patients with oropharyngeal or esophageal cancer [23]. Other authors proposed to use laparoscopy or open gastrostomy, or the push instead of the pull technique, to avoid tumor cell seeding [22].…”

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

“…Patient age, whether old or young age, was not a risk factor for stomal metastases (mean age 59.0 ± 10.0 yr, N = 43, not reported in (24); age distribution similar for (4) Longer duration for implanted cancerous cell(s) to multiply and become grossly evident at stoma * References include: (2,7,12,15,20,(24)(25)(26)(27)30,(33)(34)(35)40,41,43). * * Includes 27 receiving PEG before any cancer therapy, and 7 undergoing PEG after known local recurrence following ablative cancer therapy (surgery, chemotherapy, or radiotherapy).…”

“…The literature is mostly scat- 1 One review article published in 2004 reviewed one single factor, the relation between cancer stage and stomal metastases in 30 reported patients (4). tered as single case reports with the largest published series comprising only three new cases (2); is often published in obscure journals; and lacks a recent comprehensive clinical review with the largest previous review comprising only 25 cases (3). 1 The literature also lacks a systematic analysis of risk factors for this complication, which would provide a rational strategy for reducing the risk of this life-threatening endoscopic complication.…”

Percutaneous endoscopic gastrostomy site metastasis from head and neck squamous cell carcinoma: Case series and literature review

“…Although the incidence of PEG site metastases is low, estimated at 0.5 – 3% [2,4,13,50], survival outcomes indicate that this complication carries a grave prognosis. The estimated survival rate of 12.9% shown in the present review, although seemingly better than that reported for other sites of distant metastatic disease in HNSCC (1–6.5%) [51,52], is likely a gross overestimation as available follow up in the case reports reviewed was well below five years.…”