Facts About Tumor Seeding at the PEG Site•Believed to occur due to multiple or traumatic passes through the oral cavity of the

instruments or the PEG itself.•Found in patients with stage II–IV head and neck cancers within 1–10 months following

PEG placement.•Associated with poor prognosis, with mean survival rate of approximately 3–4 months

after diagnosis.•Not commonly considered as the onset of symptoms often mimics localized infection

with redness, induration, pain and drainage.•Symptoms resolve temporarily with antibiotic therapy.

Other Theories of Tumor Implantation•Hematogenous and lymphatic spread: According to this theory, surgical stress increases

tumor metastasis due to high concentrations of circulating cortisol, which can induce morphologic changes in the capillary lumen. This allows tumor cells to implant in the incision site due to an increase in circulation to the incision and the nutrient-rich environment of the healing site.

•Active tumor cell sloughing into the gastrointestinal tract: It is believed that as tumor cells turn over and slough from the primary site, the cells are swallowed. Following PEG placement, these slough cells adhere to the stomach wall at the PEG incision site, which is a nutrient-dense environment that nourishes the cells and promotes further cell growth.

Head and Neck Tumor Seeding at the Percutaneous Endoscopic Gastrostomy Site: A Review of the Literature and Case ReportJune Greaves, RD, CNSD, CD-N. Apria Healthcare.

Gauderer-Ponsky “Pull”Developed in 1980. The stomach is filled with air, which pushes the stomach wall up toward the abdominal wall. A light on the tip of the endoscope is turned upward, allowing viewing of the abdominal wall. A needle or catheter is placed through the abdominal wall into the stomach. After a small incision is made in the abdominal and gastric walls, a guide wire is passed through the needle/catheter site and is captured with a polypectomy snare. The endoscope, snare, and guide wire are pulled through the stomach, up the esophagus, and out of the mouth. The gastrostomy tube is then attached to the guide wire. The guide wire is pulled out of the abdominal wall, pulling the gastrostomy tube from the mouth, down the esophagus and stomach, and out through the abdominal incision. This method usually requires two passages of the endoscope through the oral cavity and one passage of the PEG through the oral cavity.

Sachs-Vine “Push”Developed in 1983. The PEG is a long, semi-rigid, tapered tube with a dilator attached to the proximal end. During the EGD, the dilator is inserted over a guide wire and advanced into the mouth, down the esophagus, into the stomach and pushed out the abdominal wall through the incision site. This method usually requires two passages of the endoscope, and one passage of the PEG, through the oral cavity.

Russell “Introducer”Developed in 1984. The stomach is filled with air and a needle is placed in the stomach. A 16-French peel-away introducer sheath and dilator is pushed over the guide wire into the stomach and abdominal wall. The dilator and guide wire are removed, leaving the introducer sheath in place. A 14-French balloon tip foley catheter is placed into the introducer sheath, and the catheter balloon is inflated and pulled up against the abdominal wall, bringing the stomach wall into position with the abdominal wall. This method only requires one passage of the instruments through the oral cavity and no passage of the PEG through the oral cavity. However, the PEG is generally smaller, such as a 14-French, rather than the standard PEG of 20-24-French.

Brown-Muller T-FastenerThis method is a modification of the Russell “Introducer.” The stomach is pulled up against the abdominal wall with nylon anchoring devices, similar to those used to attach price tags to clothing and other items. The anchoring devices are backloaded into a needle, which is passed percutaneously through the abdominal and stomach walls under endoscopic guidance. The T-bars are placed in a four corner pattern, and the introducer-dilator is centered in the middle of the pattern. Following an incision, a guide wire is advanced into the stomach with the assistance of a cannula, and a balloon tip catheter is inserted. The balloon is inflated in the stomach. The external portion of the T-fasteners is cut at the skin level approximately 2 weeks after the PEG is placed. The internal portions of the T-fasteners are excreted via stool. This method resulted in fewer post-placement infections and occurrences of metastatic cancer at the PEG site. One potential complication is ulceration at the T-bar site, which can cause ulceration and necrosis of the abdominal and stomach walls. Once the T-bars are released, the internal portion of the T-bar can become imbedded into the abdominal or gastric wall.

Case Report A 68-year-old male who had T2N0M0 squamous cell carcinoma of the hypopharynx was referred to a large national home enteral provider for EN therapy. The patient underwent PEG placement for EN in November 2009. Unfortunately, the method of PEG placement was not noted. On February 23, 2010, the patient reported that the PEG site was red, blistered, and painful, adding that he had been treated for local infection twice since PEG placement. He was advised to contact his physician for biopsy of the site. According to the patient, the physician was not overly concerned. The patient completed chemotherapy and radiation therapy and began to transition to oral intake. On March 2, 2010, the patient reported that he had not used his feeding tube for nearly 1 week, was able to maintain weight with an oral diet, and was scheduled to have the PEG removed. However, he added that the PEG site remained red and raw, with granulating tissue that was bleeding. After the PEG was removed, the patient reported to the dietitian that the PEG site was beginning to heal and that the breakdown was responding to antacid liquid applied to the skin for what was diagnosed as an ulcer at the PEG site. The patient was discharged from the home enteral provider in March 2010.

The patient suffered a recurrence of pharyngeal cancer and underwent a total larngopharyngectomy and right radical neck dissection on June 9, 2010. The previous PEG site was biopsied intraoperatively, and results confirmed metastatic carcinoma consistent with hypopharyngeal cancer. The abdominal wall contained a large mass extending from the skin surface down through the wall of the stomach. The patient required a subtotal gastrectomy with sleeve reconstruction of the abdominal wall, and a tracheoesophageal puncture was performed for enteral feedings. In March of 2011, the patient died from complications related to his metastatic carcinoma.

Reported Cases of Tumor Seeding•Mincheff reported a case of a 59-year-old male who had stage IV squamous cell carcinoma

of the right soft palate, tonsillar fossa, retromolar trigone, and base of the tongue. One month after PEG placement, granulation tissue was forming. Within 3 months, the patient had a 4-cm fungating mass around the PEG site. Three weeks later, the mass had grown to 9 cm in diameter. A skin biopsy revealed squamous cell carcinoma that originated from the patient’s head and neck cancer. An EGD demonstrated tumor growth around the bumper and mushroom in the stomach, and a computed tomography scan revealed a large mass extending through the abdominal wall.

•Sinclair et al reported a case of a 61-year-old male with stage III squamous cell carcinoma on the right side base of the tongue. PEG was placed using the “Pull” method. Approximately 5 days after PEG placement, the patient reported mild tenderness and erythema near the PEG site. The patient was treated with oral antibiotics for presumed cellulitis, with resolution of symptoms. The PEG was removed 4 months later, but the patient noted soreness at the PEG site. The site later became erythematous, raised, and indurated. The patient was treated with another week of oral antibiotics for presumed cellulitis. When no improvement was seen 6 weeks later, the site was biopsied. The biopsy was positive for squamous cell carcinoma similar to the head and neck cancer. An EGD revealed a 6-cm fungating mass along the anterior wall of the stomach. The patient underwent surgical resection of the tumor and subtotal gastrectomy, local radiation and chemotherapy. Nine weeks following surgery, biopsy results of an enlarged left axillary lymph node were positive for squamous cell carcinoma.

ConclusionClinicians working with head and neck cancer patients should be aware of all potential complications of PEG placement, including the unique complication of tumor seeding, in order to provide early intervention. Evaluation of the PEG site should be conducted if persistent or recurring redness or induration, skin breakdown, bleeding, or unusual changes are noted to the skin or stoma site, and tumor seeding should be a serious consideration in these rare cases.

More than 15,000 cases of head and neck cancers are diagnosed each year and patients often require enteral nutrition (EN) via a gastrostomy tube. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is a minimally invasive procedure. There are three main methods of PEG placement: the Gauderer-Ponsky “pull,” the Sachs-Vine “push,” and the Russell “introducer” methods. Approximately 1% of those head and cancer patients who have PEG placement using the Gauderer-Ponsky “pull” method develop metastatic cancer at the PEG site that is consistent with head and neck cancer morphology. This method places the PEG tube by pulling it through the mouth, where it passes by the tumor prior to passing through the abdominal wall.

Head and neck cancer patients often require alternative means of nutrition support due to obstructing tumors of the neck, esophagus and thyroid as well as dysphagia related to disease or radiation therapy. Before the development of PEG tubes, patients underwent open gastrostomy tube placement for long-term nutrition support. Today, most PEG tubes are placed during a complete esophagogastro-duodenoscopy (EGD). If short-term nutrition support — defined as four to six weeks — is planned, a nasogastric (NG) tube may be used.

Abstract

Introduction

Commonly Used PEG Placement Techniques

Images from the National Institutes of Health/Department of Health and Human Services.