Abstract
Background
Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent.
Methods
A comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases.
Results
The literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months.
Conclusions
Metastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the “pull” technique of PEG placement may directly implant tumor cells at the gastrostomy site.
1
Introduction
Patients with head and neck malignancies frequently present with odynophagia or dysphagia. These symptoms may arise as a result of tumor blockage or as a result of treatment. In these cases, percutaneous endoscopic gastrostomy (PEG) tubes can be used to provide nutritional support, avoid dehydration, and improve quality of life. This procedure is considered to be safe and effective, and about 75 000 PEG tubes are placed every year in the United States for various reasons . Complications are uncommon but include local infection, hemorrhage, incorrect tube placement or dislodgment, peritonitis, bowel perforation, and aspiration pneumonia . The phenomenon of cancer metastasis to PEG stomata, although rare, is becoming increasingly reported. Most cases of cancer metastasis at gastrostomy stoma have occurred with head and neck tumors .
2
Methods
A National Library of Medicine literature search was performed (1962-2011), and case reports and references were reviewed. Patient demographics, tumor location, cancer type, TNM classification, time interval between PEG placement and diagnosis of PEG site metastasis, insertion technique, and treatment before PEG placement were studied ( Table 1 ). Three cases of metastasis of head and neck cancer to a PEG stoma site diagnosed in our centers are described.
| Reference | Cancer histology and stage | Primary tumor location | Insertion method | Metastasis interval (mo) | Concurrent metastasis |
|---|---|---|---|---|---|
| 1977 Alagaratnam | SCCA, 4 | Oropharynx, larynx | Open | 24 | None |
| 1989 Preyer | SCCA, 4 | Nasopharynx | Pull | 3 | Lungs |
| 1991 Bushnell | SCCA, 4 | Larynx, lungs | Pull | 15 | Skin |
| 1992 Huang | SCCA, 4 | Oropharynx, larynx | Pull | 6 | Not reported |
| 1993 Heinbokel | Adenocarcinoma, 4 | Gastric, distal esophagus | Pull | 2 | Not reported |
| 1993 Laccourreye | SCCA, 4 | Hypopharynx | Pull | 11 | Liver |
| 1993 Massoun | SCCA, 4 | Oropharynx | Pull | 4 | Lungs |
| 1993 Meurer | SCCA, 4 | Oropharynx, Larynx | Pull | 12 | Lungs |
| 1993 Meurer | SCCA, 4 | Oropharynx | Pull | 15 | Lungs |
| 1994 Schiano | SCCA, 4 | Hypopharynx | Pull | 4 | Not reported |
| 1994 Sharma | SCCA, 4 | Oropharynx | Pull | 6 | None |
| 1995 Becker | SCCA, 4 | Hypopharynx | Pull | 3 | Lungs |
| 1995 Becker | SCCA, 3 | Cervical Esophagus | Pull | 5 | None |
| 1995 Lee | SCCA, 4 | Oropharynx | Pull | 13 | Gastric ligaments |
| 1995 Wilson | SCCA, 4 | Hypopharynx | Pull | Not reported | Not reported |
| 1996 Lauvin | SCCA, 4 | Esophagus | Pull | 4 | Not reported |
| 1997 Schneider | SCCA, 4 | Oropharynx | Pull | 10 | None |
| 1997 Thorbum | SCCA, 4 | Hypopharynx, larynx | Pull | 11 | Not reported |
| 1998 Potochny | SCCA, 4 | Hypopharynx | Pull | 9 | None |
| 1998 Van-Erpecum | SCCA, 4 | Hypopharynx | Pull | 2-10 | None |
| 1999 Deinzer | SCCA, 3 | Proximal esophagus | Pull | 3 | Not reported |
| 1999 Hosseini | SCCA, 3 | Distal esophagus | Pull | 5 | None |
| 2000 Brown | SCCA, 3 | Mid esophagus | Pull | 9 | Lungs, spine |
| 2000 Douglas | SCCA, 4 | Tonsillar fossa | Pull | 3 | None |
| 2000 Peghini | SCCA, 4 | Tongue | Pull | 9 | Skin, Colon, Bone |
| 2000 Peghini | SCCA, 4 | Tongue | Pull | 9 | None |
| 2001 Cossentino | SCCA, 4 | Tongue | Pull | 8 | Lung |
| 2001 Cossentino | SCCA, 2 | Tongue | Pull | 9 | None |
| 2001 Sinclair | SCCA, 3 | Tongue | Pull | 5 | Axillary nodes |
| 2002 Anath | SCCA, 4 | Floor of mouth | Pull | 3 | None |
| 2003 Maccabee | SCCA, 4 | Hypopharynx | Pull | 3 | None |
| 2003 Thakore | SCCA, 4 | Larynx | Pull | Unable to determine | Lungs, bone, skin, brain |
| 2004 Attoun | Adenocarcinoma, 4 | Tongue | Pull | 4 | None |
| 2005 Adelson | SCCA, 4 | Tongue | Not reported | 6 | Liver |
| 2005 Hawken | SCCA, 3 | Tongue | Radiologically | 14 | None |
| 2005 Khurana | SCCA ⁎ | Distal esophagus | Pull | 5 | Not reported |
| 2005 Mincheff | SCCA, 4 | Oropharynx, tongue | Not reported | 1 | None |
| 2006 Coletti | SCCA, 4 | Oropharynx | Pull | 8 | None |
| 2006 Daniels | SCCA, 4 | Oropharynx | Not reported | 6 | Not reported |
| 2008 Cappell | SCCA, 4 | Oropharynx, Esophagus | Pull | 8 | Not reported |
| 2008 Siddiqi | SCCA, 4 | Larynx | Pull | 7 | None |
| 2009 Hameed | Carcinosarcoma ⁎ | Esophagus | Not reported | Not reported | Not reported |
| 2010 Chang | SCCA, 3 | Esophagus | Pull | 5 | None |
2
Methods
A National Library of Medicine literature search was performed (1962-2011), and case reports and references were reviewed. Patient demographics, tumor location, cancer type, TNM classification, time interval between PEG placement and diagnosis of PEG site metastasis, insertion technique, and treatment before PEG placement were studied ( Table 1 ). Three cases of metastasis of head and neck cancer to a PEG stoma site diagnosed in our centers are described.
| Reference | Cancer histology and stage | Primary tumor location | Insertion method | Metastasis interval (mo) | Concurrent metastasis |
|---|---|---|---|---|---|
| 1977 Alagaratnam | SCCA, 4 | Oropharynx, larynx | Open | 24 | None |
| 1989 Preyer | SCCA, 4 | Nasopharynx | Pull | 3 | Lungs |
| 1991 Bushnell | SCCA, 4 | Larynx, lungs | Pull | 15 | Skin |
| 1992 Huang | SCCA, 4 | Oropharynx, larynx | Pull | 6 | Not reported |
| 1993 Heinbokel | Adenocarcinoma, 4 | Gastric, distal esophagus | Pull | 2 | Not reported |
| 1993 Laccourreye | SCCA, 4 | Hypopharynx | Pull | 11 | Liver |
| 1993 Massoun | SCCA, 4 | Oropharynx | Pull | 4 | Lungs |
| 1993 Meurer | SCCA, 4 | Oropharynx, Larynx | Pull | 12 | Lungs |
| 1993 Meurer | SCCA, 4 | Oropharynx | Pull | 15 | Lungs |
| 1994 Schiano | SCCA, 4 | Hypopharynx | Pull | 4 | Not reported |
| 1994 Sharma | SCCA, 4 | Oropharynx | Pull | 6 | None |
| 1995 Becker | SCCA, 4 | Hypopharynx | Pull | 3 | Lungs |
| 1995 Becker | SCCA, 3 | Cervical Esophagus | Pull | 5 | None |
| 1995 Lee | SCCA, 4 | Oropharynx | Pull | 13 | Gastric ligaments |
| 1995 Wilson | SCCA, 4 | Hypopharynx | Pull | Not reported | Not reported |
| 1996 Lauvin | SCCA, 4 | Esophagus | Pull | 4 | Not reported |
| 1997 Schneider | SCCA, 4 | Oropharynx | Pull | 10 | None |
| 1997 Thorbum | SCCA, 4 | Hypopharynx, larynx | Pull | 11 | Not reported |
| 1998 Potochny | SCCA, 4 | Hypopharynx | Pull | 9 | None |
| 1998 Van-Erpecum | SCCA, 4 | Hypopharynx | Pull | 2-10 | None |
| 1999 Deinzer | SCCA, 3 | Proximal esophagus | Pull | 3 | Not reported |
| 1999 Hosseini | SCCA, 3 | Distal esophagus | Pull | 5 | None |
| 2000 Brown | SCCA, 3 | Mid esophagus | Pull | 9 | Lungs, spine |
| 2000 Douglas | SCCA, 4 | Tonsillar fossa | Pull | 3 | None |
| 2000 Peghini | SCCA, 4 | Tongue | Pull | 9 | Skin, Colon, Bone |
| 2000 Peghini | SCCA, 4 | Tongue | Pull | 9 | None |
| 2001 Cossentino | SCCA, 4 | Tongue | Pull | 8 | Lung |
| 2001 Cossentino | SCCA, 2 | Tongue | Pull | 9 | None |
| 2001 Sinclair | SCCA, 3 | Tongue | Pull | 5 | Axillary nodes |
| 2002 Anath | SCCA, 4 | Floor of mouth | Pull | 3 | None |
| 2003 Maccabee | SCCA, 4 | Hypopharynx | Pull | 3 | None |
| 2003 Thakore | SCCA, 4 | Larynx | Pull | Unable to determine | Lungs, bone, skin, brain |
| 2004 Attoun | Adenocarcinoma, 4 | Tongue | Pull | 4 | None |
| 2005 Adelson | SCCA, 4 | Tongue | Not reported | 6 | Liver |
| 2005 Hawken | SCCA, 3 | Tongue | Radiologically | 14 | None |
| 2005 Khurana | SCCA ⁎ | Distal esophagus | Pull | 5 | Not reported |
| 2005 Mincheff | SCCA, 4 | Oropharynx, tongue | Not reported | 1 | None |
| 2006 Coletti | SCCA, 4 | Oropharynx | Pull | 8 | None |
| 2006 Daniels | SCCA, 4 | Oropharynx | Not reported | 6 | Not reported |
| 2008 Cappell | SCCA, 4 | Oropharynx, Esophagus | Pull | 8 | Not reported |
| 2008 Siddiqi | SCCA, 4 | Larynx | Pull | 7 | None |
| 2009 Hameed | Carcinosarcoma ⁎ | Esophagus | Not reported | Not reported | Not reported |
| 2010 Chang | SCCA, 3 | Esophagus | Pull | 5 | None |
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