Cancer Metastasis at PercutaneousEndoscopic Gastrostomy Stomata Is Related tothe Hematogenous or Lymphatic Spread ofCirculating Tumor CellsMichael C. Brown, M.D.Division of Gastroenterology, Department of Medicine, University of Washington Medical Center,Seattle, Washington

ABSTRACTPercutaneous endoscopic gastrostomy (PEG) has become amainstay in providing enteral access for patients with ob-structive oropharyngeal and esophageal tumors. PEG tubeplacement is considered safe, and complications are infre-quent. One complication, although rare, that is being in-creasingly reported is the metastasis of cancer at PEG sto-mata. Herein, a case of metastasis of an esophageal cancerat a PEG stoma is described. Although it has been previ-ously suggested that cancer metastasis is due to direct seed-ing of the stoma, an analysis of the literature suggests thatthis phenomenon is related to the hematogenous or lym-phatic spread of cancer cells to a susceptible site. (Am JGastroenterol 2000;95:3288–3291. © 2000 by Am. Coll. ofGastroenterology)

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) tubes, first de-scribed by Gaudereret al. (1), have become a mainstay inproviding long-term enteral nutrition to patients unable totake adequate oral nutrition. PEG tubes are commonlyplaced in patients with neurological deficits and in patientssuffering from obstructive esophageal, laryngeal, andpharyngeal cancers (2, 3). Complications are uncommonbut include local infection, hemorrhage, incorrect tubeplacement or dislodgment, peritonitis, bowel perforation,and aspiration pneumonia (2). The phenomenon of cancermetastasis at PEG stomata, although rare, is being in-creasingly reported. Most cases of cancer metastasis atgastrostomy stomata have occurred with head and necktumors (4 –19).Herein, a case of metastasis of an esophagealcancer at a PEG stoma is described, and previously reportedcases are reviewed. An analysis of the literature suggests thatcancer metastasis at PEGstomata is related to the hematog-enous or lymphatic spread of circulating tumor cells to asusceptible site.

CASE REPORT

A 64-yr-old male presented with dysphagia in December1997. A barium esophagram revealed an 8–10-cm mass inthe middle third of the esophagus. At endoscopy, there wasa semicircumferential, fungating, friable mass between 25and 34 cm in the mid esophagus. Because of relative ob-struction of the esophagus, sequential dilation of the esoph-agus was achieved with Savory dilators (27 F, 30 F, and 33F) with moderate resistance. A PEG tube was then placedusing thepull technique (1), and endoscopic biopsies of theesophageal mass were obtained. Histological examinationrevealed squamous cell carcinoma. Clinical workup docu-mented stage III squamous cell carcinoma of the esophagus.The patient was treated with radiation therapy, with a sub-sequent decrease in tumor size.

The patient remained fairly well until June 1998, when hedeveloped intractable back pain and was found to havecancer metastasized to the second lumbar vertebrae, withextension into the psoas muscle. The patient was treatedwith narcotics and radiation therapy to the vertebrae, withsome relief. In October 1998, the patient developed respi-ratory distress. CT and bronchoscopy revealed multiplepulmonary metastases, one of which was nearly obstructingthe left main stem bronchus and which required bronchialstent placement. During this hospitalization, prominent, fri-able tissue was seen surrounding the patient’s PEG tube atthe stoma. The PEG tube was still functioning well. ThePEG stoma was revised, and biopsies showed well-differ-entiated, infiltrating, squamous cell carcinoma. The patientdeclined further treatment and eventually succumbed to thepulmonary metastases.

DISCUSSION

The spread of cancer to a gastrostomy stoma was first reportedin 1977 by Algaratham (4). Since then, 20 additional cases ofcancer metastasis at gastrostomy stomata have been identified(5–22). The case reported here brings the total to 22.

Several observations can be made by reviewing the com-

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pilation of these case reports (Table 1). First, almost allcases involved advanced (stage III or IV) squamous cellcarcinomas of the head and neck region. The exceptions tothis observation are an adenocarcinoma of the distal esoph-agus and two squamous cell carcinomas of the middle anddistal esophagus. Second, cancer metastasis at gastrostomystomata became evident at a mean of 8 months (range, 2–24

months) after gastrostomy tube placement and was oftenconcurrent with metastases at other sites, particularly thelungs. Third, the risk of metastasis does not seem to berelated to whether the primary tumor was surgically resected(resection had occurred in 50% of the cases) or whether thegastrostomy tube remained in situ (the tube was removedbefore cancer implantation in 40% of the cases). Fourth,

Table 1. Cases of Cancer Implantation at Gastrostomy Stomata

Reference(first author, yr)

Cancer Histologyand Stage*

Primary TumorLocation

TumorContamination of

PEG Tube†

MetastasisInterval‡

(mo)ConcurrentMetastases

Alagaratnam, 1977 SCC, stage IV(T4N2M0)

Oropharynx,larynx

No§ 24 None

Preyer, 1989 SCC, stage IV(T4N2cM0)

Nasopharynx Yesi 3 Lungs

Bushnell, 1991 SCC, stage IV(T4N3bM0)

Larynx, lungs No§ 15 Skin

Huang, 1992 SCC, stage IV(T4N2aM0)

Oropharynx Yes 6 NR

Meurer, 1993 SCC, stage IV(T4N2cM0)

Oropharynx,larynx

Yes 12 Lungs

Meurer, 1993 SCC, stage IV(T4NXM0)

Oropharynx Yes 15 Lungs

Laccourreye, 1993 SCC, stage IV(T4NXM0)

Hypopharynx Yes 11 Liver

Massoun, 1993 SCC, stage IV(T4N1M0)

Oropharynx Yes 4 Lungs

Heinbokel, 1993 Adenoca, stage IV(T4NXM0)

Gastric cardia,esophagus

Yes 2 NR

Schiano, 1994 SCC, stage IV(T4N2M0)

Hypopharynx Yes 4 NR

Sharma, 1994 SCC, stage IV(T4N3M0)

Oropharynx Yes 6 None

Wilson, 1995 SCC, stage IV(T4NXMX)

Hypopharynx Yes NR NR

Lee, 1995 SCC, stage IV(T4N2bM0)

Oropharynx Yes 13 Gastricligaments

van Erpecum, 1995 SCC, stage IV(T4N0M0)

Hypopharynx Yes 2–10 None

Becker, 1995 SCC, stage IV(T4N3M0)

Hypopharynx Yesi 3 Lungs

Becker, 1995 SCC, stage III(T3N1M0)

Cervicalesophagus

Yesi 5 Localrelapse

Schneider, 1997 SCC, stage IV(T4N0M0)

Oropharynx Yes 10 None

Thorburn, 1997 SCC, stage IV(T4N3M0)

Hypopharynx,larynx

Yes 11 NR

Potochny, 1998 SCC, stage IV(T2N2M0)

Hypopharynx Yes 9 None

Hosseini, 1999 SCC, stage II/III Distalesophagus

Yes 2 None

Deinzer, 1999 SCC, stage III(T4N1M0)

Proximalesophagus

Yesi 3 NR

Brown, 2000 SCC, stage III(T4NXM0)

Mid esophagus Yesi 9 Lungs,spine

NR 5 not reported.* SCC 5 squamous cell carcinoma; Adenoca5 adenocarcinoma.† Except where indicated, all gastrostomy tubes were placedp.o., potentially causing tumor contamination of the gastrostomy tube and bumper.‡ Time lag (in months) between gastrostomy tube placement and documentation of cancer metastasis at the gastrostomy stoma.§ The report by Alagaratnam and Ong involved a surgically placed gastrostomy tube. The report by Bushnellet al. involved a PEG tube placed 6 wk after tumor resection.i PEG tube placement was preceded by bougienage dilation.

3289AJG – November, 2000 Cancer Metastasis at PEG Stomata

aside from the first report (which involved a surgicallyplaced gastrostomy tube), all the cases involved PEG tubesplacedper os (using the Ponskypull or Sachs-Vinepushtechnique; see Ref. 2).

It is believed that cancer metastasis at gastrostomy sto-mata is a direct result of the gastrostomy procedure. This isprimarily based on the fact that oropharyngeal, laryngeal,and esophageal cancers rarely metastasize to the body of thestomach. Unfortunately, the mechanism of cancer metasta-sis at gastrostomy stomata remains unclear, and the relativeimportance of the gastrostomy technique remains contro-versial. Although controlled experiments designed to ad-dress these issues are unlikely to ever be conducted, acritical analysis of the reported cases and a review of therelated literature may help clarify these issues.

Several authors have advanced the hypothesis that cancermetastasis at gastrostomy stomata is related to direct seed-ing of the stomata by tumor cells contaminating the surfaceof the gastrostomy tubes (9, 12, 14, 15, 17, 18). Thishypothesis seems to be supported by the compilation of casereports (Table 1): 20 of the 22 cases involved PEG tubesplacedper os in such a fashion that the tubes were likelycontaminated with tumor cells as they were being broughtthrough the pharynx and esophagus. This hypothesis isattractive by virtue of its simplicity and its agreement withcommon sense. In addition, this hypothesis is strengthenedby numerous analogous reports of cancer spreading to bi-opsy and needle tracks (23, 24). However, thedirect seedinghypothesis is weakened by the fact that most PEG tubes areplacedper os (2) and that thus, any case series of PEGcomplications would seem to be associated with this tech-nique.

An alternative hypothesis is that cancer metastasis atgastrostomy stomata is related to either hematogenous orlymphatic spread of tumor cells (8, 25, 26). This hypothesisis in agreement with accepted ideas regarding the mecha-nism of cancer metastasis (27) and is suggested by analysisof the collected case reports (Table 1): two of the 22 cases(9%) involved gastrostomy tubes that could not have beencontaminated by the primary tumor. These cases involvedone surgically placed gastrostomy tube and one PEG tubethat was placed 6 wk after the primary tumor was resected.Although these two cases are the exceptions, they argueagainst the hypothesis that cancer metastasis is dependenton direct seeding of stomata by contaminated gastrostomytubes.

Further analysis of the 22 case reports supports the role ofhematogenous or lymphatic spread of cancer to gastrostomystomata. In the majority of cases, the primary tumors hadknown lymph node invasion (before gastrostomy tubeplacement), and in half the cases, distant metastases werediscovered previously or concurrently with the stomal me-tastasis. This implies that tumor cells were circulating in thelymphatic channels and bloodstream and suggests that can-

cer metastasis to gastrostomy stomata is related to hema-togenous or lymphatic spread. This hypothesis is supportedby the results of a previous investigation of 35 cases ofesophageal carcinoma metastatic to the stomach (26).

Evidence for stomal metastasis via a hematogenous orlymphatic route can also be found in animal experiments. Inexperiments on mice, it was found that sites of surgicaltrauma had increased rates of tumor metastasis (28). Thiswas related to the extent of trauma and the stage of healing.Researchers postulated that circulating tumor cells selec-tively implanted in wounds because of increased circulationat the site of injury and because of the conducive environ-ment of the healing wound. The healing wound (rich infibrin, fibronectin, platelets, and inflammatory cells) entrapscirculating tumor cells and provides them with an opportu-nity for adhesion, protection from host defenses, and aninitial source of nutrients (27, 28).

The conclusions of these experiments are supported bycase reports involving cancer metastasis at sites of surgicaltrauma. One case report details the metastasis of gastricadenocarcinoma to various sites, including a jejunostomy, aprior chest tube site, and an enterocutaneous fistula (29).Two other reports refer to the metastasis of tumors tojejunostomy sites (8, 25). These reports, taken in conjunc-tion with the experimental animal evidence, suggest thathealing surgical wounds are particularly susceptible to tu-mor implantation.

In conclusion, there is considerable evidence suggestingthat cancer metastasis at gastrostomy stomata is primarilyrelated to the hematogenous or lymphatic spread of circu-lating tumor cells. This implies that the method of PEG tubeplacement does not alter or affect the risk of cancer metas-tasis at gastrostomy stomata. Furthermore, this suggests thatPEG tube placementper osis acceptable even in the pres-ence of advanced oropharyngeal or esophageal cancer.

This is not to say that the possibility of cancer metastasisat PEG stomata should be ignored. Although current rec-ommendations favor PEG tube placement before surgicalresection or intensive radiation therapy of head and neckcancer (30–32), it appears that this practice may be associ-ated with an increased risk of cancer implantation at thePEG stoma. As has been suggested elsewhere (6, 17, 19),deferring PEG tube placement until after successful resec-tion of the primary cancer may minimize (but not eliminate)the risk of cancer metastasis at PEG stomata.

ADDENDUM

Since acceptance of this article, further literature review hasrevealed additional cases of esophageal cancer metastasiz-ing to stomata. Two cases involved metastasis to PEGstomata (33, 34) and one case of a metastasis to a thoraco-scopic port-site (35).

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ACKNOWLEDGMENTS

The author thanks Dr. Christina Surawicz and Dr. MichaelKimmey for reviewing the manuscript.

Reprint requests and correspondence:Michael C. Brown, M.D.,Associates in Gastroenterology, 2296 Opitz Boulevard, Suite 240,Woodbridge, VA 22191.

Received and accepted Mar. 18, 1999.

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