Problematic PEG: A Case of Enteral Feeding Tube Seeding Malignancy to the Abdominal Wall

Abstract

The patient is a 57yo African American male with a history of tonsillar squamous cell carcinoma who presented with abdominal pain, distention and leakage from his enteral feeding tube site. He underwent uncomplicated percutaneous gastrostomy and tracheostomy placement following cancer resection surgery 3 years prior. The tracheostomy was removed shortly afterward, but gastrostomy tube was retained for medications and nutrition. Over the next several months, the patient developed worsening pain and drainage at the gastrostomy tube site. He then developed an exophytic mass that grew rapidly to surround the gastrostomy tube and tract. A CT scan of the abdomen described a 5.5 x 4.0cm solid, left anterior abdominal wall mass along the percutaneous gastrostomy tube tract. The patient underwent biopsy of the mass, which showed metastatic invasive tonsillar squamous cell carcinoma. Upon identification of metastatic cancer, the patient was tried on several systemic chemotherapeutic treatments without improvement. The treatment regimen was supplemented with palliative local radiation to the abdominal wall metastasis. For over 6 months following the addition of palliative radiation, the metastatic mass remained quiescent and the patient was symptom free. He was able to use the enteral feeding tube for nutrition and medications without complication. Despite thorough treatment, the mass enlarged and gastrostomy leakage returned. A gastrostomy-jejunostomy tube was placed, which temporarily helped control the leakage and improved delivery of medications and nutrition. During the last two months of the patient's life, he was transitioned to parenteral nutrition supplementation. He was eventually started on a patientcontrolled anesthesia regimen for pain control and discharged to inpatient hospice. Following surgical intervention for many head and neck cancers, patients typically require tracheostomy and enteral feeding tube placement to allow for adequate healing. Seeding of an enteral feeding tube site with oral, head and neck cancers is a rare occurrence. Two theories for seeding currently exist: hematogenous spread versus direct tumor transplantation during endoscopic placement usually seen with traumatic PEG placement or multiple passes of the endoscope during placement of the enteral feeding device. In the setting of development of metastasis to the abdominal wall, local chemoradiation can be used to improve quality at the end of life. This case highlights the importance of utilizing local chemoradiation as a palliative measure for certain patients. Palliative care in this situation should be personalized to the patient, and should include discussion of enteral or parenteral feeding options if indicated in the end of life.Figure 1Figure 2Figure 3