ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Uncommon Complication of Percutaneous Endoscopic Gastrostomy Tube Placement Calvin H. Y. Chan,1 Martin D. Weltman,1 and Stuart Adams2 1

Department of Gastroenterology, and 2Department of Anatomical Pathology, Nepean Hospital, NSW, Australia

Question: A 75-year-old nursing home resident was referred by her local medical officer with a 5-month history of an enlarging exophytic growth from around her percutaneous endoscopic gastrostomy (PEG) site. Her initial PEG was placed 7 years prior, when she suffered a large cerebral hemorrhage, with secondary oropharyngeal dysphagia. At the time, she was already suffering from early cognitive impairment, which had progressed over the subsequent years. The growth was noticed after a new feeding tube was replaced percutaneously, without endoscopic assistance, when the previous PEG was accidentally dislodged. In the months leading up to her assessment, there were observations from the patient’s family of altered behavior, including frequent gesturing at the PEG site, suggestive of some associated discomfort. Examination of the PEG site revealed a 3-cm, exophytic, fleshy mass that encircled the PEG tube (Figure A). No ulceration was evident. The origin of the lesion seemed to arise deep to the cutaneous layer. The PEG tube seemed to be freely mobile and was in good position. No evidence of organomegaly, ascites, or peritonism was identified on examination. A biopsy was performed of the lesion (Figure B). Computed tomography was performed (Figure C–E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.02.041

Gastroenterology 2014;147:e3–e4

ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 2: PEG Site Metastatic Adenocarcinoma Histology of the lesion revealed atypical glandular elements demonstrating severe architectural and cytological atypia, consistent with adenocarcinoma. Immunoperoxidase staining for cytokeratin 7 and 20, and CDX2 was positive. Estrogen and progesterone receptors and PAX 8 were negative. Computed tomography demonstrated soft tissue thickening surrounding the PEG tube insertion site, which seemed to be contiguous with the gastric wall, deep to the abdominal wall. No other mass lesions were seen in the stomach. There were multiple heterogeneous hypodense lesions throughout both lobes of the liver, suggestive of hepatic metastasis. Multiple, subcentimeter pulmonary opacities were also identified, suspicious for metastasis. The patient’s cognitive impairment and dysphasia limited clinical history, but the histologic and radiologic appearances are suggestive of metastatic adenocarcinoma to the PEG site. Although the primary site was not confirmed in this patient, metastatic adenocarcinoma of a gastrointestinal origin with distant spread seems most likely. There are numerous reports of tumor seeding after PEG placement in head and neck and esophageal cancers, but in this patient there was no evidence of digestive tract malignancy upon initial PEG placement, and it would be unusual for this to occur 7 years after initial insertion. Rare cases of hematogenous or lymphatic spread of malignant cells have been described at PEG sites, without the possibility of direct inoculation,1 which have been supported by animal models. It is postulated that circulating tumor cells preferentially implant at wound sites because of favorable environments.2 Local contiguous spread from a primary gastric cancer remains a differential, but there was a lack of adjacent gastric wall abnormality on computed tomography, making metastatic deposition more likely. In view of the patient’s comorbidities, a palliative approach to management was undertaken. This case demonstrates that not all exophytic growths around PEG sites are related to granulation tissue, and histologic assessment is useful if the appearances are atypical.

References 1. 2.

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Brown MC. Cancer metastasis at percutaneous endoscopic gastrostomy stomata is related to the hematogenous or lymphatic spread of circulating tumor cells. Am J Gastroenterol 2000;95:3288–3291. Tsai JK, Schattner M. Percutaneous endoscopic gastrostomy site metastasis. Gastrointest Endosc Clin North Am 2007; 17:777–786.

An uncommon complication of percutaneous endoscopic gastrostomy tube placement.

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