S2346 Metastatic Implantation of Esophageal Adenocarcinoma to PEG Tube Site: A Case Report

Abstract

Introduction: Patients with esophageal cancer often need a Percutaneous Endoscopic Gastrostomy (PEG) tube to provide nutrition. However, metastasis of the original tumor to the gastrostomy site may occur as a rare, but noteworthy complication. Case Description/Methods: A 64-year-old male had a PEG tube placed after he was diagnosed with Stage 2 esophageal adenocarcinoma with extension into the proximal stomach in Sep 2018. Following this, he received chemo and radiation therapy and did well. A follow up EGD demonstrated no evidence of malignancy, but a non-malignant duodenal narrowing / stenosis was noted. Subsequently, the patient suffered persistent leakage around his PEG tube; due to this and duodenal stenosis, his gastrostomy tube (G-tube) was removed and a jejunostomy tube (J-tube) was placed with surgical closure of the gastrostomy site (Figure). A few months later, when the patient was admitted with melena and severe anemia, an upper endoscopy performed revealed a hard, 3-4 cm malignant appearing mass with recent evidence of bleeding noted on the greater curvature of the stomach at the previous PEG tube site. Biopsies from this area showed invasive moderately differentiated adenocarcinoma with histological features similar to the previous adenocarcinoma. Though re-initiation of chemotherapy and radiation did result in improvement of the patient’s stomach neoplasm, his wound healing complications at the J-tube site persisted, resulting in delay of his treatment. In October 2021, there was recurrence of his stomach cancer. Due to persistent difficulties with wound healing and recurrent illnesses, the patient elected to forgo further treatment in favor of comfort care. He subsequently passed away peacefully. Discussion: Our experience with this case and review of the literature indicate that, in patients with esophageal cancer, usage of the “pull-string” technique as well as length of time of PEG tube placement are associated with a significantly higher risk of metastatic implantation. To avoid this rare complication, potential alternative techniques such as the “push” technique for PEG tube placement or radiologically / surgically placed G-tubes or J-tubes should be considered in patients with oropharyngeal or esophageal cancer for nutrition.Figure 1.: Endoscopic image revealing a malignant-appearing mass on the greater curvature of the stomach at initial PEG tube site.