Minimally invasive treatment of peristomal metastases from gastric cancer at an ileostomy site by electrochemotherapy

Abstract

Background: Peristomal metastases are rare, but potentially associated with relevant morbidity. Surgical resection, followed by stoma relocation, represent the gold standard in most patients. We describe electrochemotherapy (ECT), a minimally invasive method for locally-enhancing drug delivery by means of electric pulses, as an alternative approach.

Patient and methods: A 49-year-old man with advanced gastric cancer developed skin metastases around an ileostomy site. The ulcerated and oozing tumor growth impaired patient's quality of life due to continuous trouble in fitting the ostomy appliance, its poor adherence and consequent stools spillage. ECT consisted of a 20-minute course under mild general sedation. A bleomycin bolus of 15 000 IU/m(2) was followed by the percutaneous application of multiple, 1.5 ms -long electric pulses by means of a needle electrode.

Results: Post ECT course was uneventful and the patient was discharged on the same day. After one week, tumor nodules were flattened and partial tumor regression was appreciable at one-month follow-up. More importantly, peristomal skin conditions significantly improved, thus allowing for an effective application of the ostomy appliance during the following moths, until patient's death.

Conclusions: This report suggests the feasibility of ECT as a minimally invasive approach for peristomal tumors. In selected cases, ECT, by achieving a rapid tumor control, may ensure effective ostomy management and preserve patients' quality of life.

Keywords: electrochemotherapy; ileostomy; palliative care; skin care; stomach neoplasms.

FIGURE 1.

Electrochemotherapy of peristomal skin metastases. Eight minutes after intravenous injection, bleomycin molecules are equally distributed in body tissues. Tumor nodules are briefly exposed to a train of eight consecutive, high voltage (1000 V/cm), square-wave, 100-ms electric pulses, delivered at a repetition frequency of 5000 Hz by means of a needle electrode inserted into tumor tissue and connected to a pulse generator. As a consequence, transient pores open on the cell membrane and enable bleomycin concentration and entrapment, thus increasing its cytotoxic activity.

FIGURE 2.

Peristomal skin tumor infiltration from gastric cancer at the ileostomy site. Baseline clinical presentation (A, B). The histological examination (E.E.) showed a dermal infiltration of neoplastic cells with atypical and eccentric nuclei, with nucleoli and pale cytoplasm and a signet ring aspect (C), immunoreaction for CAM5.2 (D).

FIGURE 3.

Electrochemotherapy treatment. The patient in the operating room and the electric pulse generator (arrow) (A). The ECT field (B). The application of electric pulses by means of the needle electrode (arrow) (C). Early postoperative skin conditions, with slight erythema at the electrode insertion sites (arrowheads) and partial tumor bluish coloration due to voltage-induced vasoconstriction (arrows) (D).

FIGURE 4.

Post treatment wound dressing. Stoma powder application to absorb moisture from broken skin (A). Covering with an hydrocolloid dressing (B). Insertion of a silicon tube into the stoma to drain the stools and sealing of the hydrocolloid dressing with a stoma paste (arrows) (C). Effective application and sealing of the ileostomy flange and bag (D).

FIGURE 5.

Follow-up. Clinical presentation one week after ECT (A). Application of the ileostomy bag on the hydrocolloid dressing (B). Clinical presentation three weeks after ECT (C). Effective application of the ileostomy bag on the abdominal wall (D).