A 72-year-old woman presented in April 2001 with a history of progressive dysphagia to solids of 4 months’ duration with associated weight loss. An initial gastroscopy was unsuccessful. Examination under anaesthetic by the ear, nose and throat surgeons revealed a fungating, posterior hypopharyngeal wall tumour extending to the lateral walls of both pyriform fossae and up to 22 cm of the cervical oesophagus distally (Figure 1). Histology of the lesion showed it to be a squamous cell carcinoma. Computed tomography of the neck showed bilateral involvement of level 3 and 4 cervical lymph nodes and the tumour was staged as T4 N2. A decision was made to treat the patient with chemoradiotherapy because the tumour was large and exophytic. On May 1 2001, a Freka® (Fresenius Kabi, Hamburg, Germany) percutaneous endoscopic gastrostomy (PEG) tube was placed under anaesthetic, using the pull (Ponsky-Gauderer) technique, for feeding purposes before the planned oncological management. Between May and December 2001, the patient underwent a course of chemoradiotherapy. This period was complicated by neutropenic sepsis, mucositis, confusional state and peripheral neuropathy (secondary to cisplatin therapy), but responded to conservative management. A computed tomography scan of the head excluded cerebral metastases. Follow up in January 2002 showed complete clearance of the hypopharyngeal tumour and hence a decision was made to wean her off the PEG feeding and encourage an oral diet. At the time of removal of PEG tube in April 2002, nearly a year after insertion, the PEG site appeared to show an overproliferation of granulation tissue (Figure 2). This was surgically debrided, and histology showed this to be a well-differentiated keratinizing squamous cell carcinoma (Figure 3) identical to the primary hypopharyngeal lesion, raising the possibility of tumour implantation secondary to the pull technique used for PEG tube insertion. Gastroscopy confirmed tumour infiltration (Figure 4) into the lumen of stomach, and biopsy of this also proved to be of squamous cell carcinoma. Further staging investigations revealed the advanced nature of the tumour with liver metastases and hence she was referred for palliative radiotherapy. Radiotherapy alleviated the malodour from the tumour and also bleeding and overproliferation. She died peacefully in October 2002, about 6 months after the diagnosis of the stomal site cancer.

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