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nosing, moderately differentiated squa− mous cell carcinoma (SCC) of the proxi− mal esophagus. Tumor stage was cT3± 4N1M0. The patient underwent radioche− motherapy with curative intent. A percu− taneous endoscopic gastrostomy (PEG) was placed using the standard pull− through method. After 5 months the patient noticed a skin alteration at the site of the PEG, which was regarded as granulation tissue (l" Fig. 1). In a routine gastroscopy 2 months later, an ulcer at the gastric site of the PEG was found (l" Fig. 2), and initi− ally diagnosed as adenocarcinoma. Com− puted tomography demonstrated a tumor mass along the PEG−tube (l" Fig. 3). Addi− tionally, a suspicious hypodense hepatic lesion was detected. Complete local esophageal tumor control was document− ed. At laparotomy, a frozen section of the liver lesion showed a poorly differenti− ated SCC. Therefore, palliative subtotal gastrectomy with en bloc resection of the abdominal wall was carried out (l" Fig. 4). Since the first description of PEG in 1980 [1], it has become a valuable method for nutritional support. The implantation of oropharyngeal or esophageal cancer at PEG stoma sites is a rare complication with an unknown incidence [2]. The aver− age period of time from tube placement to metastatic spread is reported to be ap− proximately 9 months (range 3 ±18 months) [3]. Length of survival following this complication is rarely reported, and varies between 2 and 28 months [4]. The mechanism of tumor spread to the PEG site is controversial. Hematogenous or lymphatic spread to a susceptible site, as well as ± more likely ± direct mechanical implantation at the time of the PEG placement are proposed [3± 5]. To avoid mechanical tumor implantation, the con− tact of the PEG tube with the tumor should be minimized. In patients with bulky, stenosing tumors this can be achieved by using a sheath or overtube. Alternatively, radiologic or operative pla− cements can be carried out.

Implantation of an esophageal squamous cell carcinoma at the site of a percutaneous endoscopic gastrostomy