Port Placement for Chemotherapy in Gastric Cancer
For an older patient with gastric carcinoma requiring chemotherapy, a totally implantable venous access device (port/chemoport) should be placed via the subclavian or internal jugular vein approach by an experienced operator, as ports are the standard of care for long-term chemotherapy administration in gastric cancer patients. 1, 2
Indications and Timing
Port placement is indicated for patients with gastric cancer who will receive prolonged chemotherapy, whether in the perioperative setting (FLOT or ECF/ECX regimens requiring 4-6 months of treatment) or palliative setting (sequential lines of chemotherapy with median survival <1 year). 1, 3, 4, 5
The port should be placed before initiating chemotherapy to avoid repeated peripheral venipunctures and complications associated with peripheral administration of vesicant chemotherapy agents like oxaliplatin, cisplatin, and docetaxel. 6, 7
Chemotherapy can be safely started on the first day after port placement in 74% of patients, eliminating delays in treatment initiation. 7
Technical Considerations for Port Placement
The procedure should be performed by experienced operators (surgeons, interventional radiologists, or oncologists with procedural training) to minimize complications, as complication rates are <2% in experienced hands versus up to 46% in inexperienced hands. 2
Ultrasound-guided venous access is preferred to reduce mechanical complications like pneumothorax, hemothorax, and arterial puncture, though these serious complications are rare with proper technique. 6, 2
The port reservoir should be placed in the subcutaneous tissue of the anterior chest wall (infraclavicular region) with the catheter tip positioned in the superior vena cava at the cavoatrial junction. 2
Special Considerations in Older Patients
Age alone is not a contraindication to port placement or chemotherapy in gastric cancer patients, though careful assessment of performance status (ECOG ≤2 or Karnofsky ≥60%) and comorbidities is essential. 1
For elderly patients (≥72 years), consider dose-reduced chemotherapy regimens (e.g., 60% dose reduction of capecitabine/oxaliplatin), which are noninferior with better tolerability, making port placement still appropriate. 1
Assess cardiac function before port placement in older patients, as fluoropyrimidine-based chemotherapy (5-FU, capecitabine) can cause cardiotoxicity including angina, myocardial ischemia, and arrhythmias. 8
Complication Rates and Management
Overall complication rates range from 4.3% to 46%, with the most common being infection (0.8-7.5%), catheter malposition (9.2%), drug extravasation (5.0%), thrombosis (3.3%), and wound dehiscence (2.5%). 6, 2, 7
Early infection (≤30 days) occurs in approximately 4% of patients, while late infection (≥30 days) also occurs in 4%, requiring port removal and systemic antibiotics in most cases. 7
Catheter-related thrombosis occurs in 1-3.3% of patients and should be managed with anticoagulation while maintaining port function if possible. 6, 7
Serious complications like pneumothorax, hemothorax, and brachial plexus injury are rare (<2%) when proper technique is used. 6, 2
Port Care and Maintenance
Meticulous aseptic technique during port access is critical to prevent bloodstream infections, which occurred in 4% of patients in one series. 7
The port should be flushed with heparinized saline after each use and at least monthly when not in use to maintain patency. 2
Patients and caregivers require education on port care, including signs of infection (fever, erythema, tenderness at port site), thrombosis (arm swelling, pain), and catheter dysfunction (inability to aspirate blood or infuse fluids). 2
Alternative Considerations
Peripherally inserted central catheters (PICCs) are NOT preferred for gastric cancer chemotherapy due to higher infection rates, thrombosis risk, and patient discomfort compared to ports. 2
For patients with peritoneal carcinomatosis from gastric cancer, a separate intraperitoneal port system may be considered for bidirectional chemotherapy (intraperitoneal plus systemic), though this is investigational and not standard practice. 9
If port placement is contraindicated (severe coagulopathy, active infection, superior vena cava syndrome), consider temporary central venous catheter placement or correction of contraindications before port insertion. 2
Common Pitfalls to Avoid
Do not delay port placement until after chemotherapy complications occur with peripheral access, as this increases patient suffering and treatment delays. 7
Do not place ports in patients with ECOG performance status 3-4, as these patients should receive best supportive care only, not chemotherapy. 1
Do not use the port for blood draws or infusions other than chemotherapy without proper training, as improper technique increases infection and catheter damage risk. 2
Do not ignore early signs of port complications (fever, pain, swelling), as prompt recognition and management prevent serious sequelae like sepsis or pulmonary embolism. 6, 7