PEG-Implantationsmetastase eines Ösophaguskarzinoms – Fallbericht und Literaturübersicht

Zusammenfassung

Wir berichten den Fall eines 54-jährigen Patienten, bei dem aufgrund eines mäßig differenzierten Plattenepithelkarzinoms des proximalen Ösophagus (cT 3–4, N 1, M 0) eine perkutane endoskopische Gastrostomie (PEG) angelegt wurde. Anschließend erfolgte unter kurativem Therapieansatz eine Radiochemotherapie. Etwa fünf Monate nach Therapiebeginn stellte der Patient eine Hautveränderung an der PEG-Austrittsstelle fest, die zunächst vom Hausarzt als Granulationsgewebe eingestuft wurde. Weitere sechs Wochen später zeigte eine auswärts durchgeführte Verlaufsgastroskopie ein Ulkus neben der gastralen PEG-Andruckplatte, aus der eine Biopsie entnommen wurde. Das vordiagnostizierte Ösophaguskarzinom war endoskopisch zu diesem Zeitpunkt nicht mehr nachweisbar. Histologisch handelte es sich bei dem Granulationsgewebe entlang der PEG-Sonde um eine Bauchdeckenmetastase des vorbestehenden Ösophaguskarzinoms. Trotz subtotaler Magenresektion mit En-bloc-Resektion des Tumors entwickelte der Patient Fernmetastasen und verstarb etwa sechs Monate später. Bis heute wurden in der Literatur weltweit 47 Fälle von Bauchwandfiliae als Spätkomplikation nach PEG-Anlage berichtet, wobei der Metastasierungsmechanismus noch immer kontrovers diskutiert wird. Da die direkte Tumorzellverschleppung als wahrscheinlichster Mechanismus angenommen werden kann, sollte im Einzelfall bei fortgeschrittenen, stenosierenden Tumoren eine alternative Methode, z. B. operativ (laparoskopisch) oder radiologisch, zur Anlage einer Gastrostomie erwogen werden.

Abstract

We describe the case of a 54-year-old man with a tumour of the proximal esophagus (cT3–4,N1,M0), who underwent percutaneous endoscopic gastrostomy (PEG) for enteral feeding. Primary radiochemotherapy was initiated shortly after PEG insertion. Five months after PEG insertion the patient detected a nodule at the site. The general practitioner diagnosed this nodule as a brotic reaction. Another six weeks later, ulceration that had grown along the PEG probe at the PEG site was observed on gastroscopy. The primary tumour was not visible. Histological examination showed an abdominal wall metastasis of the esophageal cancer. Despite subtotal gastrectomy with en-bloc resection of the tumour, distant metastasis developed. The patient died six months after surgery. About 47 cases of abdominal wall metastases as late complications at the site have been reported until now. The mechanism of tumour spread of PEG site is a subject of controversial discussion. As direct mechanical tumour implantation is the most likely mechanism, an alternative method like operative (laparoscopic) or radiological PEG placement should be considered in cases with advanced, stenotic tumours.

Schlüsselwörter

perkutane endoskopische Gastrostomie - Ösophaguskarzinom - Implantationsmetastase - Fistelkarzinom

Key words

percutaneous endoscopic gastrostomy - esophageal carcinoma - metastatic implantation - fistular carcinoma

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1 K. Volkmer und T. Meyer sind gleichberechtigte Erstautoren.