Carcinoma of the colon presenting as bilateral ovarian tumors during pregnancy

Diagnostic, Management, and Neonatal Outcomes of Colorectal Cancer during Pregnancy: Two Case Reports, Systematic Review of Literature and Metanalysis

OBJECTIVE

Colorectal cancer (CRC) during pregnancy is a rare occurrence, with a reported incidence of 0.8 cases per 100,000 pregnancies. Managing CRC during pregnancy poses substantial challenges for clinicians: the diagnosis is often complicated and delayed due to symptom overlap with pregnancy-related manifestations, and medical imaging is constrained by safety concerns for the foetus.

METHODS

This article presents two cases of advanced CRC diagnosed and managed during pregnancy. Additionally, we conducted a systematic review of the literature to assess diagnostic and prognostic factors involved in CRC in pregnant individuals. The systematic review, with pre-registration and approval through Prospero, involved an extensive search of medical databases (Pubmed, Web of Science, Scopus and Scholar) and statistical analysis using t-test for continuous variables and chi square for dichotomous variables.

RESULTS

A total of 1058 studies were identified. After applying exclusion criteria, sixty-six studies were included. Women whose initial symptoms were severe abdominal pain not responsive to common medical treatments and constipation (acute abdomen) had a mean gestational age at delivery lower than those who presented with paucisymptomatic onset. In our study groups, women who underwent chemotherapy during pregnancy had a higher mean gestational age at delivery and did not experience worse neonatal outcomes compared to those who did not undergo chemotherapy.

CONCLUSIONS

CRC during pregnancy poses unique diagnostic and therapeutic challenges. Collaborative efforts among various medical disciplines are essential to manage CRC during pregnancy.

Cancer in Pregnancy

This article reviews some of the more common types of cancer that may be encountered during pregnancy. It reviews the unique challenges with the diagnosis and treatment of breast, cervical, hematologic, and colon cancers in pregnant patients.

Colon Cancer in Pregnancy: Report of a Case and Review of the Literature

Most colon cancer cases occur in patients over 50 years of age, although about 3% of colorectal cancer patients are younger than 40. During pregnancy the incidence of this neoplasm is estimated to be 0.002%. To date only 32 cases of colonic cancer arising above the peritoneal reflection during pregnancy have been described in the literature. We report another such case, stressing the need for constant alertness on the part of physicians in the presence of abdominal pain and/or distension, a palpable abdominal mass, rectal bleeding and/or weight loss during pregnancy. In fact, the reportedly poorer prognosis of this cancer in pregnant patients is mainly due to the fact that the initial symptoms of the malignancy are usually attributed by the patient, but also by physicians, to normal pregnancy.

Colorectal cancer diagnosed during pregnancy: systematic review and treatment pathways

The aim of this study was to identify the mode of presentation and incidence of colorectal cancer in pregnancy (CRC-p), assess the outcomes of the mother and foetus according to gestational age, treatment delivered and cancer features and location. A systematic review of the literature was carried out to identify studies reporting on CRC-p and pooled analysis of the reported data. Seventy-nine papers reporting on 119 patients with unequivocal CRC-p were included. The calculated pooled risk is 0.002% and age at diagnosis has decreased over time. The median age at diagnosis was 32 (range, 17-46) years. Twelve per cent, 41 and 47% of CRC-p were diagnosed during the first, second and third trimester. The CRC-p site was the colon in 53.4% of cases, the rectum in 44% and multiple sites in 2.6%. Bleeding occurred in 47% of patients, abdominal pain in 37.6%, constipation in 14.1%, obstruction in 9.4% and perforation in 2.4%. Out of 82 patients whose treatment was described, 9.8% received chemotherapy during pregnancy. None of their newborns developed permanent disability, one developed hypothyroidism and 72% of newborns were alive. Vaginal delivery was possible in 60% of cases. Anterior resection was performed in 30% of patients and abdominoperineal excision of the rectum in 14.9%. Five patients had either synchronous (60%) or metachronous liver resection (40%). The median survival in these patients was 42 (0-120) months. Fifty-five per cent of patients were alive at the last available follow-up. The median survival of the mother was 36 (0-360) months. Patients with rectal cancer had longer survival compared with patients with colon cancer (P=0.0072). CRC-p is rare, leading to symptoms being overlooked, and diagnosis made at advanced stages. Cases described in the literature include patients who had cancer before pregnancy or developed it after delivery. Survival has not increased over time and the management of these patients requires collaboration between specialties and active interaction with the patients.

Feto-maternal outcomes of pregnancy complicated by Krukenberg tumor: a systematic review of literature

PURPOSE

Krukenberg tumor is a rare type of ovarian cancer with a poor prognosis, and little is known about its behavior during pregnancy.

METHODS

A systematic review was conducted to identify pregnancies complicated by Krukenberg tumor, correlated to oncologic and neonatal outcomes (n = 35).

RESULTS

Mean age of cases was 30.4 years, and the most common origin of primary cancer was the stomach (68.6 %) followed by the colon (14.3 %). The two most common presenting symptoms were abdominal/pelvic pain (51.4 %) and nausea/vomiting (48.6 %). Two-thirds of tumors were bilateral (65.7 %) and the average size was 16.7 cm. Ascites (45.7 %), carcinomatosis (25.7 %) and non-ovarian distant metastases (14.3 %) were found at the time of surgery. Chemotherapy was administered in 20 cases, with fetal exposure in two of these. The ovarian tumor was identified prior to the primary cancer diagnosis in all 28 cases. The overall number of live births was 27 (81.8 %). The median survival was 6 months after Krukenberg tumor diagnosis. In univariate analysis, decreased overall survival was associated with dyspnea, ascites, carcinomatosis, non-radical surgery for the primary cancer, and residual disease at surgery (all, p < 0.05). On multivariate analysis, dyspnea and carcinomatosis remained independent prognostic factors for decreased overall survival after Krukenberg tumor diagnosis (2-year overall survival rates, dyspnea 0 vs. 56.6 %, adjusted-hazard ratio [HR] 9.74, 95 % confidence interval [CI] 2.04-46.2, p < 0.01; and carcinomatosis, 0 vs. 58.1 %, adjusted-HR 7.95, 95 % CI 1.76-36.0, p < 0.01).

CONCLUSIONS

Our results showed that prognosis of Krukenberg tumor complicated pregnancies is extremely poor, however it may be improved if radical surgery is achievable.

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

Flexible sigmoidoscopy and colonoscopy during pregnancy

More than 6000 pregnant women each year have an indication that warrants a flexible sigmoidoscopy or colonoscopy. In addition to the potential complications inherent in the risk of sedation and the procedures themselves, the endoscopist who performs these procedures in pregnant women must be aware of the potential to do harm to the fetus. This article reviews the existing literature as it pertains to flexible sigmoidoscopies and colonoscopies performed during pregnancy, including indications and diagnostic usefulness, safety, use of medications, and therapeutic interventions.

Gastrointestinal, Pancreatic, and Hepatic Cancer During Pregnancy

Pregnancy affects the clinical presentation, evaluation, treatment, and prognosis of patients with gastrointestinal cancer. Pregnant patients may present with advanced gastrointestinal cancer as a result of delayed diagnosis, in part because of difficulty differentiating signs and symptoms of cancer from signs and symptoms of normal pregnancy. The approach to cancer surgery and chemotherapy must be modified in pregnant patients to minimize fetal and maternal risks. Because of these factors, women who develop gastrointestinal cancers during pregnancy seem to have a poor prognosis. This article focuses on cancers of the colon, stomach, pancreas, and liver that occur during pregnancy.

Colorectal cancer associated with pregnancy in Kaduna

The incidence of colorectal cancer associated with pregnancy is low. Only 2-6% of all females suffering from colorectal cancer are within the child bearing age (i.e. under 40 years). This paper describes the experience at the Ahmadu Belle University Teaching Hospital, Kaduna, Nigeria, from 1 January 1975 to 31 December 1997. Twenty-five cases of colorectal cancer associated with pregnancy were seen and treated; 15 cases in which colorectal cancer occurred de novo in pregnant patients; and 10 cases in which pregnancy(ies) occurred in patients with a previous diagnosis of colorectal cancer. Treatment of the cancer, future pregnancies and their management, and the question of possible prophylactic oophorectomy in selected patients are discussed.

Colon cancer during pregnancy

The medical community should become mobilized to diagnose colon cancer earlier in pregnancy to improve prognosis. The primary care physician or obstetrician should refer the pregnant patient with significant gastrointestinal complaints to the gastroenterologist for evaluation. Likewise, the gastroenterologist should be prepared to perform sigmoidoscopy, preferably without endoscopic medications, for significant lower gastrointestinal symptoms such as persistent rectal bleeding. Sigmoidoscopy is particularly sensitive in identifying colon cancer in pregnant patients because their cancers are usually distal and within reach of the sigmoidoscope.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.

Colon cancer during pregnancy. The gastroenterologist's perspective

Colon cancer during pregnancy is uncommon but not rare, with an estimated incidence of several hundred cases per year in the United States. This type of cancer tends to have a poor prognosis that is attributable to delays in diagnosis and advanced disease at diagnosis. The diagnosis frequently is delayed because symptoms of colon cancer, such as rectal bleeding, nausea and vomiting, and constipation, often are attributed to normal pregnancy or minor complications of pregnancy. Pregnancy affects the diagnostic evaluation and therapy of colon cancer because of fetal risks of diagnostic tests and therapy. Appropriate medical evaluation of significant lower gastrointestinal complaints during pregnancy can lead to an earlier and improved diagnosis.

Cancer in pregnancy: a review of the literature. Part I

Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.

Colon and rectal cancer in pregnancy

Colorectal carcinoma presenting in pregnancy is an uncommon disease that is reported to be associated with an extremely poor prognosis. To better characterize this disease, we surveyed the membership of the American Society of Colon and Rectal Surgeons by mailed questionnaire and reviewed the literature. Forty-one new cases of women with large bowel cancer who presented during pregnancy or the immediate postpartum period were identified. The mean age at presentation was 31 years (range, 16-41 years). Tumor distribution was as follows: right colon-3, transverse colon-2, left colon-2, sigmoid colon-8, and rectum-26. Dukes stage at presentation was A = 0, B = 16, C = 17, and D = 6 (two patients were unstaged). Average follow-up was 41 months. Stage for stage, survival was found to be similar to patients with colorectal tumors in the general population. Large bowel cancer coexistent with pregnancy presents in a distal distribution (64 percent of tumors in the current series and 86 percent of those reported in the literature were located in the rectum) and presents at an advanced stage (60 percent were Stage C or more advanced at the time of diagnosis). While patient survival is poor, it is no different stage for stage from the general population with colorectal tumors.

Colon carcinoma during pregnancy: a lethal coincidence

Carcinoma of the colon during pregnancy is rare. A 38-year-old woman with an obstructive adenocarcinoma of the left colon diagnosed at 27 weeks of gestation is described. Three months and 21 months after hemicolectomy a right, subsequently left ovariectomy was performed because of metastatic disease. Three years after initial surgery, which was followed by chemotherapy, the patient died of metastatic disease. Until now 26 cases of colon cancer during pregnancy have been described; none of these patients have survived 5 years. Metastatic spread of colon cancer to the ovaries in pregnant patients is frequently observed (25%). The fetal risk is very small, because placental and fetal involvement in maternal malignancy is rarely observed, even in widespread metastatic disease.

Intussusception caused by a carcinoma of the cecum during pregnancy: report of a case and review of the literature

A case of intussusception due to a carcinoma of the cecum during pregnancy is reported. A 27-year-old pregnant female was admitted to Shimodate Municipal Hospital because of abdominal pain, nausea and vomiting. Her abdomen was distended, and a relatively hard mass was palpable in the right hypochondrium. Following a diagnosis of intussusception by ultrasonography, a laparotomy was performed. The lesion causing the intussusception was found to be a carcinoma of the cecum, and thus a right hemicolectomy with lymph node dissection was carried out. Histological examination revealed that the tumor was a well-differentiated adenocarcinoma which had invaded the muscularis propria but was superficial to the subserosa. None of the lymph nodes were cancerous. The incidence of colonic cancer above the peritoneal reflection during pregnancy is very low. Only 24 cases have been previously reported; our patient is only the 25th case, as well as being the first case demonstrating Dukes' A. Due to the intussusception, ultrasonography was effective for diagnosis and the patient was able to undergo a curative operation at an earlier stage than other patients.

Colonic cancer during pregnancy: case report and review of the literature

Colonic cancer during pregnancy is rare. Herein we describe a case of adenocarcinoma of the transverse colon in a 29-year-old pregnant patient. Early diagnosis is difficult because the initial symptoms of colorectal cancer, such as abdominal pain, nausea and vomiting, constipation, and abdominal distention, are often attributed to a normal pregnancy. Management of colonic cancer during pregnancy depends on gestational age and operability of the tumor. Medical and surgical management considerations are discussed.

Perforated adenocarcinoma of the colon during pregnancy

Performated carcinoma of the colon in pregnant women is a rare event. Only six cases have been reported in the literature, all except one in the recto-sigmoid. We present a case of perforated adenocarcinoma of the colon located above the peritoneal reflection and discuss the problem of diagnosis and management.

Malignant ovarian tumors associated with pregnancy: report of six cases

Six cases of pregnancy associated malignant ovarian tumors, four epithelial cancers, one immature teratoma and one metastatic cancer of colon origin, are reported. One patient with mucinous cystadenocarcinoma had a history of persistent ovarian tumor during her past three pregnancies. Another patient was found to have mucinous cystadenocarcinoma after an emergency operation for twisted ovarian tumor. Immature teratoma associated with pregnancy is very rare and our case seems to be the 8th reported such case.