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Implantation of oral squamous cell carcinoma at the site of apercutaneous endoscopic gastrostomy: a case report
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British Journal of Oral and Maxillofacial Surgery (2002) 40, 125–130 © 2002 The British Association of Oral and Maxillofacial Surgeons doi: 10.1054/bjom.2001.0740, available online at http://www.idealibrary.com on
Journal of Oral and Maxillofacial Surgery
Implantation of oral squamous cell carcinoma at the site of a percutaneous endoscopic gastrostomy: a case report S. Ananth,* M. Amin† *Department of Oral and Maxillofacial Surgery, Royal Berkshire Hospital, Reading, UK; †S.W. London Maxillofacial Service, Queen Mary’s Hospital, London, UK SUMMARY. A 55-year-old man had an operation and radiotherapy for a squamous cell carcinoma of the oral cavity and developed a metastatic deposit at the site of a percutaneous endoscopic gastrostomy, with no other evidence of systemic spread. Treatment of the metastasis was by neo-adjuvant chemotherapy with cisplatin and 5-fluorouracil (5-FU) followed by en bloc resection of the stomal recurrence on the anterior abdominal wall. There has been no evidence of recurrence to date. Only 17 other cases of metastasis to this site from a primary tumour in the upper aerodigestive tract have been reported. We review the relevant publications and discuss the techniques, complications and possible mechanisms of spread and their implications for the use of percutaneous endoscopic gastrostomy in head and neck cancer surgery. © 2002 The British Association of Oral and Maxillofacial Surgeons
INTRODUCTION Gauderer et al.1 first described the technique of percutaneous endoscopic gastrostomy (PEG) in 1980. Since then it has become increasingly used as an alternative to conventional surgical gastrostomy for nutritional support in patients with head and neck cancer, as it is considered to be a safer procedure with a lower complication rate, is less invasive, generally well-tolerated and more costeffective. Metastatic implantation of tumour at the PEG exit site on the abdominal wall is a rare complication. We report the eighteenth case of tumour implantation at the PEG site from a squamous cell carcinoma (SCC) of the upper aerodigestive tract. Fig. 1 Histology of the moderately differentiated SCC arising in the floor of the mouth (H&E,100).
CASE REPORT sedation using a standard ‘pull’ technique with no immediate complications. The following day the intraoral tumour was resected and a modified radical neck dissection done. Adjuvant postoperative radiotherapy was given to the site of the primary tumour and both sides of the neck (60 Gy). Two weeks after the completion of radiotherapy, the patient was readmitted for pain control and rehydration as a result of severe radiation-induced mucositis. He had been using the PEG tube infrequently. At 12 weeks after the operation leakage was noted around the PEG site on the anterior abdominal wall, associated with a small amount of granulation tissue. This was cauterized with silver nitrate. As the patient had a persistently low haemoglobin concentration (0.9 g/l) he was given a four-unit blood transfusion. Oesophagogastroduodenoscopy showed evidence of mild generalized gastritis but no other abnormalities. At 14 weeks after
A 55-year-old white man with a history of tobacco and alcohol misuse who was under the care of the haematologists for chronic anaemia and weight loss was referred with a 3-month history of a lump in the left neck. Clinical examination showed a 1.5-cm ulcer in the left floor of the mouth and a 6-cm mass in the left mid-cervical region. Biopsy specimens of the ulcer and the neck mass showed moderately differentiated SCC (Fig. 1) and metastatic SCC, respectively. There was no evidence of distant metastatic disease and the clinical staging was T1N2aM0 SCC of the floor of the mouth. In view of his chronic anaemia and weight loss a whole-body computed tomogram (CT) was done which confirmed a mass in the left neck but showed no evidence of any other systemic disease (Fig. 2). A PEG tube was placed (12F Corflo, Merck Biomaterial), under intravenous 125
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Fig. 4 Non-keratinizing poorly differentiated metastatic SCC around the PEG site (H&E,100).
Fig. 2 Axial CT scan showing the left cervical mass.
Fig. 5 Axial CT scan of the abdomen showing a large mass encasing the PEG tube extending from the anterior stomach wall to the abdominal wall.
site in the floor of the mouth (Fig. 4). A repeat whole-body CT confirmed an irregular subcutaneous mass on the anterior abdominal wall at the site of emergence of the PEG tube (Fig. 5), but no other evidence of systemic spread, and a bone scan was unremarkable. Surgical and oncological opinions were obtained, and the patient subsequently had a course of chemotherapy with cisplatin and 5-fluorouracil (5-FU) followed by wide local excision of the metastasis at the PEG site down to and including a disc of anterior stomach wall. A feeding jejunostomy tube was inserted. There were no postoperative complications and the patient was discharged home a few days later. The histology report confirmed a moderately well-differentiated SCC arising at the junction between the skin and stomach wall, which seemed to have been excised completely. To date the patient has not developed any evidence of recurrence either from the floor of mouth or the PEG site. Fig. 3 Metastatic SCC at the PEG exit site.
DISCUSSION the operation extensive granulation tissue was noted around the PEG site (Fig. 3), which was biopsied and shown to be a nonkeratinizing poorly differentiated SCC with no epidermal elements, highly suggestive of a metastasis from the primary
In most patients with head and neck cancer the gastrointestinal tract remains functional, and enteral feeding is the preferred route of nutritional support. Since its
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Table 1 Summary of published cases of SCC implantation at PEG site in patients with head and neck cancer: all PEGs were inserted using the ‘pull’ method First author
Year
Reference number
Age (years)/ sex
Site/stage of primary tumour
Treatment of primary tumour
Other metastases
Length of survival
Preyer
1989
13
Bushnell
1991
14
Huang
1992
15
72 Male 68 Male 53 Male
Chemotherapy, 3 PEG, radiotherapy Surgery, PEG, 17 radiotherapy PEG, surgery, 6 radiotherapy
Laccourreye
1993
16
65 Male
Pharynx T4N2M0 Supraglottic T4N3bM0 Posterior pharynx T4N2aM0 Hypopharynx T1N1M0
Pulmonary
6 months
Pulmonary
18 months
Not reported
Not reported
Radiotherapy, Chemotherapy, PEG, surgery
11
Hepatic
PEG, surgery, radiotherapy PEG, radiotherapy PEG, surgery, radiotherapy PEG, surgery, radiotherapy, chemotherapy
12
Pulmonary
Abdominal radiotherapy; died 15 months postoperatively 28 months
Meurer (case 1) Meurer (case 2) Massoun
1993
17
1993
17
1993
18
Sharma
1994
19
45 Male 76 Female 58 Male 40 Male
Supraglottic T4N2M0 Oropharynx T4N0M0 Tongue T4N1M0 Floor of mouth T4N3M0
16 4.5
Pulmonary, mediastinal Pulmonary
6
No evidence
4
Not reported
13
No evidence
29 months
Hypopharynx T4N3M0
Chemotherapy, PEG, radiotherapy Surgery, radiotherapy, chemotherapy, PEG, further surgery PEG, radiotherapy
9 months after surgery Abdominal surgery; length of survival not reported Not reported
Schiano
1994
20
43 Male
Hypopharynx T4N2M0
Lee
1995
21
41 Male
Tongue T4N2bM0
Becker (case 1)
1995
22
49 Male
3
Pulmonary
55 Female 69 Male
Oesophagus T3N1M0 Hypopharynx T4N0M0
PEG, radiotherapy PEG, radiotherapy
5
Not reported
Abdominal surgery; died 2 months after PEG site metastasis 6.5 months
Becker 1995 (case 2) Van-Erpecum 1995
22
2
No evidence
14 months
Thorburn
1997
24
56 Male 61 Female
Surgery, PEG, radiotherapy PEG, radiotherapy, surgery
10
No evidence
15 months
10
No evidence
44 Male
Supraglottic T4N3M0 Mouth, tongue and epiglottis T4N0M0 Hypopharynx T2N2M0
Schneider
1997
25
PEG, surgery, radiotherapy
9
No evidence
27
68 Male
Oesophagus T4N0M0
4
Not reported
–
55 Male
Floor of mouth T1N2aM0
PEG, radiotherapy, chemotherapy PEG, surgery, radiotherapy
Abdominal surgery; no evidence of disease Abdominal surgery; well 4 months postoperatively Not reported
Potochny
1998
26
Deinzer
1999
Present study
–
3
No evidence
23
Time to implantation at PEG site (months)
19 months
Chemotherapy and abdominal surgery; no recurrence to date
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introduction in 1980, PEG has become increasingly popular, after surgery and radiotherapy, for improving patients’ nutritional status and reducing duration of hospital stay.1 It has superseded the use of a nasogastric tube and the traditional open Stamm gastrostomy as the commonest method of providing long-term enteral feeding because of its ease of insertion, cost-effectiveness and low reported complication rates.2–5 It is now also the preferred method for feeding in patients with severe facial trauma and dysphagia as a result of advanced neurological disease, and more recently has also been used successfully in patients who require prolonged gastrointestinal decompression. Fine-bore nasogastric tube feeding is sometimes used for short-term enteral support but is poorly tolerated and is associated with gastro-oesophageal reflux, aspiration, nasal ulceration and frequent blockage of the tube. Surgical gastrostomy has the disadvantage of requiring a laparotomy, and most studies have shown it to be associated with more complications than PEG.6,7 Various methods have been described for the percutaneous endoscopic insertion of a gastrostomy tube, of which the ‘pull’ method is the most widely used.1 An endoscope is passed into the stomach and after inspection of the stomach and duodenum, the stomach is inflated with air. A strong suture is passed through a cannula that has been inserted through a transilluminated area of abdominal wall into the stomach. The suture is grasped with the endoscopic snare, which is then withdrawn through the oesophagus and out of the mouth. The abdominal operator retains the other end of the suture. The suture is tied firmly to the end of a gastrostomy tube, traction is applied to the suture, and the tube is pulled down the oesophagus into the stomach until it engages the cannula. The cannula and the tube are then withdrawn together through a stab incision in the anterior abdominal wall until the gastric retainer rests against the inner wall of the stomach. The ‘push’ method uses an endoscopically placed guidewire to push the PEG and catheter assembly through the oropharynx, and is a modification of a technique described by Sach et al.8 The ‘introducer’ method is based on the Seldinger technique for insertion of central venous catheters and pacemaker wires.9 Under endoscopic control a guidewire is passed through a cannula into the stomach, and a tapered introducer with a split-sheath over it is passed over the guidewire. The introducer and the guidewire are removed and a small Foley catheter (14F) or similar type gastrostomy tube with an inflatable balloon is inserted through the split-sheath. The balloon is inflated and the split-sheath is peeled apart. A technique has also been described for the percutaneous insertion of a gastrostomy tube under radiological control, which does not require gastrointestinal
endoscopy.10 Laparoscopic gastrostomy and jejunostomy techniques are also under evaluation.11,12 The reported complication rates for PEG are about 5% compared with 16% for open gastrostomy, and the reported procedure-related mortality rate is 1% compared with about 4% for open gastrostomy.6,7 Major complications of PEG include compromise of the airway and aspiration pneumonia, haemorrhage, inadvertent damage to adjacent structures, dislodgement of the tube, infection of the abdominal wall, intraperitoneal leakage and peritonitis. Minor complications include gastrooesophageal reflux, dyspnoea, transient pneumoperitoneum, tube blockage, persistent pain, or infection around the PEG site and formation of granulation tissue. Technical difficulties may arise as a result of an inability to pass an endoscope past a pharyngeal or oesophageal obstruction or to appose the stomach and abdominal walls because of obesity or previous surgery. Although the prevalence is unknown, a rare but increasingly reported complication in patients with head and neck cancer is the metastatic implantation of SCC at the PEG site. Since 1989 there have been 17 reported cases of metastatic seeding of upper aerodigestive tract SCC to PEG sites13–27 (Table 1). In our patient, tumour was first noticed around the PEG site 3 months after insertion, but the mean time to PEG site implantation in previously reported cases was 8 months (range 2–17). Various theories have been proposed about the mechanism of spread of tumour to the PEG site, including direct implantation at the time of PEG, haematogenous or lymphatic spread, and shedding of tumour cells into the gastrointestinal tract which lodge at the PEG site. Gastrostomy stomal implantation is usually associated with metastatic disease at other sites, particularly the lung or mediastinum. However in six of the previously reported cases and in our case there was no evidence of metastatic disease elsewhere at the time of the implantation at the PEG site. In all the previously reported cases the ‘pull’ method of PEG was used and in most cases PEG was done before treatment of the primary tumour. There have been no reported cases of stomal seeding using the ‘introducer’ method. This raises the issue of whether implantation occurs at the time of PEG when the tube is pulled past the tumour down into the stomach. As there was no evidence of metastatic disease elsewhere, iatrogenic implantation by direct seeding seems the most likely cause in our patient. This theory is also supported by cases reported by Sharma et al.19 and Potochny et al.26 Although gastric metastases are rare in patients with head and neck cancer, another theory is that local trauma to the gastric mucosa at the time of gastrostomy predisposes to haematogenous or lymphatic seeding of malignant cells that are already within the circulation. In a case reported by Bushnell et al.14 a laryngeal carcinoma was
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resected 6 weeks before PEG with the pull-through method. Late recurrence at the PEG site occurred at the same time as radiographic diagnosis of a pulmonary mass. Alagaratnam and Ong28 reported a patient with a locally advanced SCC of the tongue who developed metastases at the site of a surgically placed gastrostomy. Haematogenous spread to a susceptible site was the proposed mechanism in this case, although iatrogenic surgical implantation from contaminated surgical instruments has also been suggested. There have also been reported cases of metastases to jejunostomy and tracheostomy sites.29 A further possible mechanism for PEG site seeding is that tumour cells that are directly shed into the gastrointestinal tract may lodge at the site of the surgical wound that has been created in the stomach wall. In conclusion, when curative resection is planned for patients with head and neck cancer, particularly bulky tumours, it may be advisable to consider PEG postoperatively. If the PEG tube is inserted before treatment of the primary tumour then the use of a sheath or overtube in the oropharynx is advisable to minimize contact of the PEG tube with the tumour. Alternatively the ‘introducer’ method or percutaneous insertion under radiological control may be better options, as the PEG tube avoids contact with the upper aerodigestive tract. Despite its drawbacks fine-bore nasogastric tube feeding may be considered when only short-term enteral feeding is required. Careful follow-up is required after PEG, with prompt biopsy of any persistent granulation tissue at the stoma site. Finally, curative treatment of any recurrence at a PEG site may be considered in selected cases. ACKNOWLEDGEMENTS We thank Mr B. M. W. Bailey, Consultant Maxillofacial Surgeon, Ashford Hospital, Middlesex, for his advice in the preparation of this paper; Dr S. K. Ibrahim, Consultant Histopathologist, Ashford Hospital, Middlesex, for his help in the preparation of the histological slides and Ms Joanne Holland, Royal Berkshire Hospital, Reading, for taking the photographs. This report was presented as a poster at the Annual Conference of the British Association of Oral and Maxillofacial Surgeons, June 2000, Bournemouth, UK.
REFERENCES 1.
Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980; 15: 872–875. 2. Wilson WR, Hariri SM. Experience with percutaneous endoscopic gastrostomy on an otolaryngology service. Ear Nose Throat J 1995; 74: 760–762. 3. Barkmeier JM, Trerotola SO, Wiebke EA et al. Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis. Cardiovasc Intervent Radiol 1998; 21: 324–328. 4. Raynor EM, Williams MF, Martindale RG, Porubsky ES. Timing of percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients. Otolaryngol Head Neck Surg 1999; 120: 479–482. 5. Campos AC, Marchesini JB. Recent advances in the placement of tubes for enteral nutrition. Curr Opin Clin Nutr Metab Care 1999; 2: 265–269.
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6. Wasiljew BK, Ujiki GTM, Veak HN. Feeding gastrostomy: complications and mortality. Am J Surg 1982; 143: 194–195. 7. Rabeneck L, Wray NP, Petersen NJ. Long term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med 1996; 11: 287–293. 8. Sach BA, Vines HS, Palestrant AM. A nonoperative technique for establishment of a gastrostomy in the dog. Invest Radiol 1983; 18: 485–489. 9. Russell TR, Brotman M, Norris F. Percutaneous gastrostomy: a new simple cost-effective technique. Am J Surg 1984; 148: 132–137. 10. Rosenzweig TB, Palenstrant AM, Esplin CA, Gilsdorf RB. A method of radiologic-assisted gastrostomy when percutaneous endoscopic gastrostomy is contraindicated. Am J Surg 1994; 168: 587–591. 11. Lathrop JC, Felix EJ, Lauber D. Laparoscopic Janeway gastrostomy utilizing an endoscopic stapling device. J Laparoendosc Surg 1991; 1: 335–339. 12. Songster W, Sandstorm L. Baroscopic feeding jejunostomy. Surg Endosc 1993; 7: 308–310. 13. Preyer S, Thul P. Gastric metastasis of squamous cell carcinoma of the head and neck after percutaneous endoscopic gastrostomy – report of a case. Endoscopy 1989; 21: 295. 14. Bushnell L, White TW, Hunter JG. Metastatic implantation of laryngeal carcinoma at a PEG exit site. Gastrointest Endosc 1991; 37: 480–482. 15. Huang DT, Thomas G, Wilson W. Stomal seeding by percutaneous endoscopic gastrostomy in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 1992; 18: 658–659. 16. Laccourreye O, Chabardes E, Merite-Drancy A et al. Implantation metastasis following percutaneous endoscopic gastrostomy. J Laryngol Otol 1993; 107: 946–949. 17. Meurer MF, Kenady DF. Metastatic head and neck carcinoma in a percutaneous gastrostomy site. Head Neck 1993; 15: 70–73. 18. Massoun H, Gerlach U, Manegold BC. Impfmetastase nach percutaner endoskopischer gastrostomie (PEG). Chirurg 1993; 64: 71–72. 19. Sharma P, Berry SM, Wilson K, Neale H, Fink AS. Metastatic implantation of an oral squamous-cell carcinoma at a percutaneous endoscopic gastrostomy site. Surg Endosc 1994; 8: 1232–1235. 20. Schiano T, Pfister D, Harrison L, Shike M. Neoplastic seeding as a complication of percutaneous endoscopic gastrostomy. Am J Gastroenterol 1994; 89: 131–133. 21. Lee DS, Mohit-Tabatabai MA, Rush BF, Levine C. Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy tube placement. Ann Surg Oncol 1995; 2: 170–173. 22. Becker G, Hess CF, Grund KE, Hoffmann W, Bamberg M. Abdominal wall metastasis following percutaneous endoscopic gastrostomy. Support Care Cancer 1995; 3: 313–316. 23. Van-Erpecum KJ, Akkersdijk WL, Warlam-Rodenhuis CC, Van-Berge-Henegouwen GP, Van-Vroonhoven TJ. Metastasis of hypopharyngeal carcinoma into the gastrostomy tract after placement of a percutaneous endoscopic gastrostomy catheter. Endoscopy 1995; 27: 124–127. 24. Thorburn D, Karim AN, Soutar DS, Mills PR. Tumour seeding following percutaneous endoscopic gastrostomy placement in head and neck cancer. Postgrad Med J 1997; 73: 430–432. 25. Schneider AM, Loggie BW. Metastatic head and neck cancer to the percutaneous endoscopic gastrostomy exit site: a case report and review of the literature. Am Surg 1997; 63: 481–486. 26. Potochny JD, Sataloff DM, Spiegel JR, Lieber CP, Siskind B, Sataloff RT. Head and neck cancer implantation at the percutaneous endoscopic gastrostomy exit site. Surg Endosc 1998; 12: 1361–1365. 27. Deinzer M, Menges M, Walter K et al. Implantation metastasis at the exit site after percutaneous endoscopic gastrostomy in oesophageal carcinoma. Z Gastroenterol 1999; 37: 789–793. 28. Alagaratnam TT, Ong GB. Wound implantation – a surgical hazard. Br J Surg 1977; 64: 872–875.
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29. Campbell AC, Gleich LL, Barrett WL, Gluckman JL. Cancerous seeding of the tracheotomy site in patients with upper aero digestive tract squamous cell carcinoma. Otolaryngol Head Neck Surg 1999; 120: 601–603.
The Authors S. Ananth BDS, DFO Senior House Officer Department of Oral and Maxillofacial Surgery Royal Berkshire Hospital Reading, UK
M. Amin FDSRCS, FRCS Specialist Registrar S.W. London Maxillofacial Service Queen Mary’s University Hospital London, UK Correspondence and requests for offprints to: Mr S. Ananth, 18 Richmond Hill Court, Richmond Hill, Surrey TW10 6BD, UK. Tel: ;44 (0) 208 940 3972; Fax: ;44 (0) 208 241 8671; E-mail: [email protected] Accepted 21 August 2001
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British Journal of Oral and Maxillofacial Surgery (2002) 40, 125–130 © 2002 The British Association of Oral and Maxillofacial Surgeons doi: 10.1054/bjom.2001.0740, available online at http://www.idealibrary.com on
Journal of Oral and Maxillofacial Surgery
Implantation of oral squamous cell carcinoma at the site of a percutaneous endoscopic gastrostomy: a case report S. Ananth,* M. Amin† *Department of Oral and Maxillofacial Surgery, Royal Berkshire Hospital, Reading, UK; †S.W. London Maxillofacial Service, Queen Mary’s Hospital, London, UK SUMMARY. A 55-year-old man had an operation and radiotherapy for a squamous cell carcinoma of the oral cavity and developed a metastatic deposit at the site of a percutaneous endoscopic gastrostomy, with no other evidence of systemic spread. Treatment of the metastasis was by neo-adjuvant chemotherapy with cisplatin and 5-fluorouracil (5-FU) followed by en bloc resection of the stomal recurrence on the anterior abdominal wall. There has been no evidence of recurrence to date. Only 17 other cases of metastasis to this site from a primary tumour in the upper aerodigestive tract have been reported. We review the relevant publications and discuss the techniques, complications and possible mechanisms of spread and their implications for the use of percutaneous endoscopic gastrostomy in head and neck cancer surgery. © 2002 The British Association of Oral and Maxillofacial Surgeons
INTRODUCTION Gauderer et al.1 first described the technique of percutaneous endoscopic gastrostomy (PEG) in 1980. Since then it has become increasingly used as an alternative to conventional surgical gastrostomy for nutritional support in patients with head and neck cancer, as it is considered to be a safer procedure with a lower complication rate, is less invasive, generally well-tolerated and more costeffective. Metastatic implantation of tumour at the PEG exit site on the abdominal wall is a rare complication. We report the eighteenth case of tumour implantation at the PEG site from a squamous cell carcinoma (SCC) of the upper aerodigestive tract. Fig. 1 Histology of the moderately differentiated SCC arising in the floor of the mouth (H&E,100).
CASE REPORT sedation using a standard ‘pull’ technique with no immediate complications. The following day the intraoral tumour was resected and a modified radical neck dissection done. Adjuvant postoperative radiotherapy was given to the site of the primary tumour and both sides of the neck (60 Gy). Two weeks after the completion of radiotherapy, the patient was readmitted for pain control and rehydration as a result of severe radiation-induced mucositis. He had been using the PEG tube infrequently. At 12 weeks after the operation leakage was noted around the PEG site on the anterior abdominal wall, associated with a small amount of granulation tissue. This was cauterized with silver nitrate. As the patient had a persistently low haemoglobin concentration (0.9 g/l) he was given a four-unit blood transfusion. Oesophagogastroduodenoscopy showed evidence of mild generalized gastritis but no other abnormalities. At 14 weeks after
A 55-year-old white man with a history of tobacco and alcohol misuse who was under the care of the haematologists for chronic anaemia and weight loss was referred with a 3-month history of a lump in the left neck. Clinical examination showed a 1.5-cm ulcer in the left floor of the mouth and a 6-cm mass in the left mid-cervical region. Biopsy specimens of the ulcer and the neck mass showed moderately differentiated SCC (Fig. 1) and metastatic SCC, respectively. There was no evidence of distant metastatic disease and the clinical staging was T1N2aM0 SCC of the floor of the mouth. In view of his chronic anaemia and weight loss a whole-body computed tomogram (CT) was done which confirmed a mass in the left neck but showed no evidence of any other systemic disease (Fig. 2). A PEG tube was placed (12F Corflo, Merck Biomaterial), under intravenous 125
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Fig. 4 Non-keratinizing poorly differentiated metastatic SCC around the PEG site (H&E,100).
Fig. 2 Axial CT scan showing the left cervical mass.
Fig. 5 Axial CT scan of the abdomen showing a large mass encasing the PEG tube extending from the anterior stomach wall to the abdominal wall.
site in the floor of the mouth (Fig. 4). A repeat whole-body CT confirmed an irregular subcutaneous mass on the anterior abdominal wall at the site of emergence of the PEG tube (Fig. 5), but no other evidence of systemic spread, and a bone scan was unremarkable. Surgical and oncological opinions were obtained, and the patient subsequently had a course of chemotherapy with cisplatin and 5-fluorouracil (5-FU) followed by wide local excision of the metastasis at the PEG site down to and including a disc of anterior stomach wall. A feeding jejunostomy tube was inserted. There were no postoperative complications and the patient was discharged home a few days later. The histology report confirmed a moderately well-differentiated SCC arising at the junction between the skin and stomach wall, which seemed to have been excised completely. To date the patient has not developed any evidence of recurrence either from the floor of mouth or the PEG site. Fig. 3 Metastatic SCC at the PEG exit site.
DISCUSSION the operation extensive granulation tissue was noted around the PEG site (Fig. 3), which was biopsied and shown to be a nonkeratinizing poorly differentiated SCC with no epidermal elements, highly suggestive of a metastasis from the primary
In most patients with head and neck cancer the gastrointestinal tract remains functional, and enteral feeding is the preferred route of nutritional support. Since its
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Table 1 Summary of published cases of SCC implantation at PEG site in patients with head and neck cancer: all PEGs were inserted using the ‘pull’ method First author
Year
Reference number
Age (years)/ sex
Site/stage of primary tumour
Treatment of primary tumour
Other metastases
Length of survival
Preyer
1989
13
Bushnell
1991
14
Huang
1992
15
72 Male 68 Male 53 Male
Chemotherapy, 3 PEG, radiotherapy Surgery, PEG, 17 radiotherapy PEG, surgery, 6 radiotherapy
Laccourreye
1993
16
65 Male
Pharynx T4N2M0 Supraglottic T4N3bM0 Posterior pharynx T4N2aM0 Hypopharynx T1N1M0
Pulmonary
6 months
Pulmonary
18 months
Not reported
Not reported
Radiotherapy, Chemotherapy, PEG, surgery
11
Hepatic
PEG, surgery, radiotherapy PEG, radiotherapy PEG, surgery, radiotherapy PEG, surgery, radiotherapy, chemotherapy
12
Pulmonary
Abdominal radiotherapy; died 15 months postoperatively 28 months
Meurer (case 1) Meurer (case 2) Massoun
1993
17
1993
17
1993
18
Sharma
1994
19
45 Male 76 Female 58 Male 40 Male
Supraglottic T4N2M0 Oropharynx T4N0M0 Tongue T4N1M0 Floor of mouth T4N3M0
16 4.5
Pulmonary, mediastinal Pulmonary
6
No evidence
4
Not reported
13
No evidence
29 months
Hypopharynx T4N3M0
Chemotherapy, PEG, radiotherapy Surgery, radiotherapy, chemotherapy, PEG, further surgery PEG, radiotherapy
9 months after surgery Abdominal surgery; length of survival not reported Not reported
Schiano
1994
20
43 Male
Hypopharynx T4N2M0
Lee
1995
21
41 Male
Tongue T4N2bM0
Becker (case 1)
1995
22
49 Male
3
Pulmonary
55 Female 69 Male
Oesophagus T3N1M0 Hypopharynx T4N0M0
PEG, radiotherapy PEG, radiotherapy
5
Not reported
Abdominal surgery; died 2 months after PEG site metastasis 6.5 months
Becker 1995 (case 2) Van-Erpecum 1995
22
2
No evidence
14 months
Thorburn
1997
24
56 Male 61 Female
Surgery, PEG, radiotherapy PEG, radiotherapy, surgery
10
No evidence
15 months
10
No evidence
44 Male
Supraglottic T4N3M0 Mouth, tongue and epiglottis T4N0M0 Hypopharynx T2N2M0
Schneider
1997
25
PEG, surgery, radiotherapy
9
No evidence
27
68 Male
Oesophagus T4N0M0
4
Not reported
–
55 Male
Floor of mouth T1N2aM0
PEG, radiotherapy, chemotherapy PEG, surgery, radiotherapy
Abdominal surgery; no evidence of disease Abdominal surgery; well 4 months postoperatively Not reported
Potochny
1998
26
Deinzer
1999
Present study
–
3
No evidence
23
Time to implantation at PEG site (months)
19 months
Chemotherapy and abdominal surgery; no recurrence to date
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introduction in 1980, PEG has become increasingly popular, after surgery and radiotherapy, for improving patients’ nutritional status and reducing duration of hospital stay.1 It has superseded the use of a nasogastric tube and the traditional open Stamm gastrostomy as the commonest method of providing long-term enteral feeding because of its ease of insertion, cost-effectiveness and low reported complication rates.2–5 It is now also the preferred method for feeding in patients with severe facial trauma and dysphagia as a result of advanced neurological disease, and more recently has also been used successfully in patients who require prolonged gastrointestinal decompression. Fine-bore nasogastric tube feeding is sometimes used for short-term enteral support but is poorly tolerated and is associated with gastro-oesophageal reflux, aspiration, nasal ulceration and frequent blockage of the tube. Surgical gastrostomy has the disadvantage of requiring a laparotomy, and most studies have shown it to be associated with more complications than PEG.6,7 Various methods have been described for the percutaneous endoscopic insertion of a gastrostomy tube, of which the ‘pull’ method is the most widely used.1 An endoscope is passed into the stomach and after inspection of the stomach and duodenum, the stomach is inflated with air. A strong suture is passed through a cannula that has been inserted through a transilluminated area of abdominal wall into the stomach. The suture is grasped with the endoscopic snare, which is then withdrawn through the oesophagus and out of the mouth. The abdominal operator retains the other end of the suture. The suture is tied firmly to the end of a gastrostomy tube, traction is applied to the suture, and the tube is pulled down the oesophagus into the stomach until it engages the cannula. The cannula and the tube are then withdrawn together through a stab incision in the anterior abdominal wall until the gastric retainer rests against the inner wall of the stomach. The ‘push’ method uses an endoscopically placed guidewire to push the PEG and catheter assembly through the oropharynx, and is a modification of a technique described by Sach et al.8 The ‘introducer’ method is based on the Seldinger technique for insertion of central venous catheters and pacemaker wires.9 Under endoscopic control a guidewire is passed through a cannula into the stomach, and a tapered introducer with a split-sheath over it is passed over the guidewire. The introducer and the guidewire are removed and a small Foley catheter (14F) or similar type gastrostomy tube with an inflatable balloon is inserted through the split-sheath. The balloon is inflated and the split-sheath is peeled apart. A technique has also been described for the percutaneous insertion of a gastrostomy tube under radiological control, which does not require gastrointestinal
endoscopy.10 Laparoscopic gastrostomy and jejunostomy techniques are also under evaluation.11,12 The reported complication rates for PEG are about 5% compared with 16% for open gastrostomy, and the reported procedure-related mortality rate is 1% compared with about 4% for open gastrostomy.6,7 Major complications of PEG include compromise of the airway and aspiration pneumonia, haemorrhage, inadvertent damage to adjacent structures, dislodgement of the tube, infection of the abdominal wall, intraperitoneal leakage and peritonitis. Minor complications include gastrooesophageal reflux, dyspnoea, transient pneumoperitoneum, tube blockage, persistent pain, or infection around the PEG site and formation of granulation tissue. Technical difficulties may arise as a result of an inability to pass an endoscope past a pharyngeal or oesophageal obstruction or to appose the stomach and abdominal walls because of obesity or previous surgery. Although the prevalence is unknown, a rare but increasingly reported complication in patients with head and neck cancer is the metastatic implantation of SCC at the PEG site. Since 1989 there have been 17 reported cases of metastatic seeding of upper aerodigestive tract SCC to PEG sites13–27 (Table 1). In our patient, tumour was first noticed around the PEG site 3 months after insertion, but the mean time to PEG site implantation in previously reported cases was 8 months (range 2–17). Various theories have been proposed about the mechanism of spread of tumour to the PEG site, including direct implantation at the time of PEG, haematogenous or lymphatic spread, and shedding of tumour cells into the gastrointestinal tract which lodge at the PEG site. Gastrostomy stomal implantation is usually associated with metastatic disease at other sites, particularly the lung or mediastinum. However in six of the previously reported cases and in our case there was no evidence of metastatic disease elsewhere at the time of the implantation at the PEG site. In all the previously reported cases the ‘pull’ method of PEG was used and in most cases PEG was done before treatment of the primary tumour. There have been no reported cases of stomal seeding using the ‘introducer’ method. This raises the issue of whether implantation occurs at the time of PEG when the tube is pulled past the tumour down into the stomach. As there was no evidence of metastatic disease elsewhere, iatrogenic implantation by direct seeding seems the most likely cause in our patient. This theory is also supported by cases reported by Sharma et al.19 and Potochny et al.26 Although gastric metastases are rare in patients with head and neck cancer, another theory is that local trauma to the gastric mucosa at the time of gastrostomy predisposes to haematogenous or lymphatic seeding of malignant cells that are already within the circulation. In a case reported by Bushnell et al.14 a laryngeal carcinoma was
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resected 6 weeks before PEG with the pull-through method. Late recurrence at the PEG site occurred at the same time as radiographic diagnosis of a pulmonary mass. Alagaratnam and Ong28 reported a patient with a locally advanced SCC of the tongue who developed metastases at the site of a surgically placed gastrostomy. Haematogenous spread to a susceptible site was the proposed mechanism in this case, although iatrogenic surgical implantation from contaminated surgical instruments has also been suggested. There have also been reported cases of metastases to jejunostomy and tracheostomy sites.29 A further possible mechanism for PEG site seeding is that tumour cells that are directly shed into the gastrointestinal tract may lodge at the site of the surgical wound that has been created in the stomach wall. In conclusion, when curative resection is planned for patients with head and neck cancer, particularly bulky tumours, it may be advisable to consider PEG postoperatively. If the PEG tube is inserted before treatment of the primary tumour then the use of a sheath or overtube in the oropharynx is advisable to minimize contact of the PEG tube with the tumour. Alternatively the ‘introducer’ method or percutaneous insertion under radiological control may be better options, as the PEG tube avoids contact with the upper aerodigestive tract. Despite its drawbacks fine-bore nasogastric tube feeding may be considered when only short-term enteral feeding is required. Careful follow-up is required after PEG, with prompt biopsy of any persistent granulation tissue at the stoma site. Finally, curative treatment of any recurrence at a PEG site may be considered in selected cases. ACKNOWLEDGEMENTS We thank Mr B. M. W. Bailey, Consultant Maxillofacial Surgeon, Ashford Hospital, Middlesex, for his advice in the preparation of this paper; Dr S. K. Ibrahim, Consultant Histopathologist, Ashford Hospital, Middlesex, for his help in the preparation of the histological slides and Ms Joanne Holland, Royal Berkshire Hospital, Reading, for taking the photographs. This report was presented as a poster at the Annual Conference of the British Association of Oral and Maxillofacial Surgeons, June 2000, Bournemouth, UK.
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The Authors S. Ananth BDS, DFO Senior House Officer Department of Oral and Maxillofacial Surgery Royal Berkshire Hospital Reading, UK
M. Amin FDSRCS, FRCS Specialist Registrar S.W. London Maxillofacial Service Queen Mary’s University Hospital London, UK Correspondence and requests for offprints to: Mr S. Ananth, 18 Richmond Hill Court, Richmond Hill, Surrey TW10 6BD, UK. Tel: ;44 (0) 208 940 3972; Fax: ;44 (0) 208 241 8671; E-mail: [email protected] Accepted 21 August 2001