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Stomal Metastases Complicating Percutaneous Endoscopic Gastrostomy: CT Findings and the Argument for Radiologic Tube Placement

¹ Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889-5600.
² Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814.
³ Department of Radiology, University of Washington, 1959 N.E. Pacific, Box 357115, Seattle, WA 98195-7115.
⁴ Gastroenterology Service, Walter Reed Army Medical Center, Bldg. 2, 7F, 6900 Georgia Ave., N.W., Washington, DC 20307.

View larger version (144K): [in a new window]   Fig. 1A. —76-year-old man with squamous cell carcinoma of tongue who presented with persistent drainage around percutaneous endoscopic gastrostomy (PEG) tube 9 months after placement. Axial contrast-enhanced CT scan shows irregular soft-tissue mass involving PEG tract (arrow). Note eccentric component at gastric entry site (arrowhead) but relatively little mass effect at cutaneous exit site. Lesion was solitary metastasis.

View larger version (143K): [in a new window]   Fig. 1B. —76-year-old man with squamous cell carcinoma of tongue who presented with persistent drainage around percutaneous endoscopic gastrostomy (PEG) tube 9 months after placement. Axial contrast-enhanced CT scan obtained 3 months before A shows clear interval progression of soft tissue around PEG tube. Minimal soft tissue (arrow) present at this point is nonspecific and appears similar to some cases with no tumor that we reviewed.

View larger version (142K): [in a new window]   Fig. 1C. —76-year-old man with squamous cell carcinoma of tongue who presented with persistent drainage around percutaneous endoscopic gastrostomy (PEG) tube 9 months after placement. Photograph from upper endoscopy shows lobulated gastric entry site mass (arrowheads) adjacent to PEG bumper, corresponding to CT finding.

View larger version (156K): [in a new window]   Fig. 1D. —76-year-old man with squamous cell carcinoma of tongue who presented with persistent drainage around percutaneous endoscopic gastrostomy (PEG) tube 9 months after placement. Photograph of PEG exit site shows mild induration of surrounding skin and small area of friable soft tissue (arrow) centrally.

View larger version (185K): [in a new window]   Fig. 2A. —64-year-old man with squamous cell carcinoma of tonsillar fossa. Axial contrast-enhanced CT scans obtained for tumor restaging 3 months before clinical presentation of stomal metastasis show lobulated soft tissue around percutaneous endoscopic gastrostomy tube (arrowheads). Associated thickening of musculus rectus abdominis (arrows) is less specific and was also seen in most patients with no stomal metastases. Coarse pancreatic calcifications are present from chronic pancreatitis, but no other sites of abdominal metastatic disease were seen. Patient presented 3 months later with peristomal bleeding from presumed granulation tissue that was later proven at pathology to be metastatic disease.

View larger version (184K): [in a new window]   Fig. 2B. —64-year-old man with squamous cell carcinoma of tonsillar fossa. Axial contrast-enhanced CT scans obtained for tumor restaging 3 months before clinical presentation of stomal metastasis show lobulated soft tissue around percutaneous endoscopic gastrostomy tube (arrowheads). Associated thickening of musculus rectus abdominis (arrows) is less specific and was also seen in most patients with no stomal metastases. Coarse pancreatic calcifications are present from chronic pancreatitis, but no other sites of abdominal metastatic disease were seen. Patient presented 3 months later with peristomal bleeding from presumed granulation tissue that was later proven at pathology to be metastatic disease.

View larger version (143K): [in a new window]   Fig. 3. —45-year-old man with squamous cell carcinoma of mid esophagus who presented with fungating mass at percutaneous endoscopic gastrostomy (PEG) exit site only 3 months after placement. Axial contrast-enhanced CT scan shows increased abdominal wall soft tissue that encases PEG tube (arrow).

View larger version (157K): [in a new window]   Fig. 4. —80-year-old man with gastric non-Hodgkin's lymphoma and no evidence of stomal metastatic disease. Axial contrast-enhanced CT scan shows expected appearance of normal percutaneous endoscopic gastrostomy tube tract, with only minimal hazy soft tissue adjacent to tube (arrows). Lymphomatous involvement of stomach, right adrenal gland, and perirenal spaces is present, in addition to gastrohepatic and retrocrural lymphadenopathy.

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