Incidence of Metastases to the Abdominal Wall Following Percutaneous Endoscopic Gastrostomy Placement in Patients with Head and Neck Cancer

Eleanor Fung, MD¹, Edward L Jones, MD², David Strosberg¹, Rebecca Dettorre¹, Andrew Suzo¹, Michael P Meara¹, Vimal K Narula¹, Jeffrey W Hazey¹. ¹The Ohio State University Wexner Medical Centre, ²Department of Surgery, University of Colorado at Denver

INTRODUCTION: Patients with head and neck malignancy are often malnourished at the time of their diagnosis and during the course of their treatment. As a result, percutaneous endoscopic gastrostomy (PEG) tubes are an effective modality for enteral nutrition given the favorable benefit-risk profile compared to nasoenteric tubes and surgical intervention; however, there have been documented case reports of “seeding” of the tract by the theoretical risk of dragging the tube along the tumor during PEG placement in patients with head and neck malignancy.  The objective of this study is to determine the incidence and contributing risk factors leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer.

METHODS AND PROCEDURES: A retrospective chart review was performed on our database of 742 patients diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/29/2014. Patients without a head and neck malignancy or without 30 day follow-up after PEG placement were excluded. The primary outcome was the development of abdominal wall metastases following PEG placement. Secondary outcomes included type of malignancy and tumor characteristics, smoking history, PEG placement technique, stomal metastasis presentation and survival following recurrence.  Data was then analyzed using basic analysis for overall trends.

RESULTS: Out of 742 patients analyzed, a total of five patients with head and neck malignancy were identified with abdominal wall metastasis following PEG tube placement for an overall incidence of 0.0067%. One patient was found to have a clinically evident and symptomatic stomal metastasis while the other four patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were found to have Stage IV cancer at time of initial diagnosis of their head & neck malignancy followed by widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis. Furthermore, all of these patients underwent PEG tube insertion via the "Pull" technique.

CONCLUSION: Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy. Potential risk factors associated with stomal metastases include advanced cancer stage, synchronous distant metastatic disease, the "Pull" technique for PEG insertion, smoking and alcohol use history as well as large primary tumor size.