Head and Neck Cancer Tumor Seeding at the Percutaneous Endoscopic Gastrostomy Site

Abstract

The National Institutes of Health National Cancer Institute estimates that over 13,000 new cases of head and neck cancer (HNC) will be diagnosed in 2017. Patients with HNC often require enteral nutrition (EN) via gastrostomy tube to provide nutrition support and hydration because of tumor obstruction of the oropharynx and/or cumulative effects of chemoradiation therapy. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is considered a minimally invasive procedure. There are 3 methods of PEG placement: Gauderer-Ponsky "pull," Sachs-Vine "push," and Russell "push" method. The Gauderer-Ponsky "pull" method has become the preferred method of PEG placement. It has been previously reported that the rate of stomal metastasis can be 0.5%-1% of those undergone the Gauderer-Ponsky "pull" method that is consistent with HNC morphology. Other researchers believe the rate may be as high as 0.5%-3%. This article reviews the 3 methods of PEG placement, as well as all potential complications, including metastatic seeding at the PEG site. In addition, 1 additional case of tumor seeding at the PEG site will be reviewed. Consideration for avoidance of the Gauderer-Ponsky pull method of PEG placement or other methods of feeding tube placement where the gastrostomy tube has to pass through the oral cavity before exiting the abdominal wall in patients with squamous cell carcinoma of the head and neck should be considered.

Squamous cell carcinoma implantation in gastrostomy orifice. Case report

“…The possibility of metastasis should always be taken into consideration in patients with HNC that present with skin changes at the gastrostomy site, which requires confirmation by biopsy. ( 8 ) The risks of tumor implantation in the abdominal wall are higher in patients of advanced age and/or advanced tumor staging. ( 6 )…”

“…A possibilidade de metástase deve sempre ser considerada em pacientes com CCP que apresentem alterações dermatológicas no sítio da gastrostomia, necessitando ser confirmadas com biópsia. ( 8 ) Os riscos de implantação tumoral na parede abdominal são maiores em pacientes de idade avançada e/ou estadiamento tumoral avançado. ( 6 )…”

“…(6) The possibility of metastasis should always be taken into consideration in patients with HNC that present with skin changes at the gastrostomy site, which requires confirmation by biopsy. (8) The risks of tumor implantation in the abdominal wall are higher in patients of advanced age and/or advanced tumor staging. (6) ❚ CONCLUSION When the endoscopy gastrostomy probe is manipulated in the region of the oropharynx with neoplasia, there is risk of inducing metastases by direct implantation of neoplastic cells into the gastric incision.…”

Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique?

“…Actually, patients with proximal GI cancers are at risk of seeding from the primary tumour site to the PEG tract by mechanical transfer. In 1989, Preyer and Thul [24] reported the first patient with PEG tract metastasis, and since then, new cases have been identified annually [24][25][26][27]. In a recent prospective controlled study involving 50 patients, positive cytology for malignant cells was described in 22.5% of the stomas immediately after PEG placement using the pull method, and after 3-6 months of follow-up, persistence of these cells was detected in 9%.…”

“…Although some cases of favourable evolution have been reported, this adverse event is often associated with a poor oncologic outcome [24,26,29]. Thus, the use of a direct gastric puncture technique for percutaneous feeding tube placement in patients with proximal GI cancer has been recommended by several authors, especially in patients receiving radical therapy with curative intent [20,25]. Comparative studies have shown similar complication rates, except for a more common occurrence of delayed tube disfunction and minor bleeding episodes with the introducer approach [30,31].…”