Management and outcome of colorectal cancer during pregnancy: report of 41 cases

Intestinal perforation due to colorectal cancer during pregnancy: case report and literature review

Colorectal cancer (CRC) in pregnancy is sporadic. We reported a case of a woman at 23 + 4 weeks of gestation who presented with abdominal pain. The patient underwent an ultrasound and MRI, during which a colonic mass was noted. Considering a probable incomplete intestinal obstruction, a colonoscopy, biopsy, and colonic stenting were performed by a multidisciplinary team. However, sudden hyperthermia and CT demonstrated intestinal perforation, and an emergency caesarean section and colostomy were conducted. The histological analysis confirmed moderately high-grade adenocarcinoma.

CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

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.

Pregnancy, delivery and neonatal outcomes in women with gastrointestinal system cancer in pregnancy. An evaluation of a population database

OBJECTIVES

Gastrointestinal system (GIS) cancer in pregnancy is a rare disease. Our aim was to evaluate the association between this type of cancer and pregnancy, delivery and neonatal outcomes.

METHODS

We conducted a retrospective population-based cohort study using the Healthcare Cost and Utilization Project, Nation-wide Inpatient Sample (HCUP-NIS). We included all women who delivered or had a maternal death in the US between 2004 and 2014. We compared women with an ICD-9 diagnosis of GIS cancer to those without. Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

A total of 9,096,788 women met inclusion criteria. Amongst them, 194 women (2/100,000) had a diagnosis of GIS cancer during pregnancy. Women with GIS cancer, compared to those without, were more likely to be Caucasian, older than 35 years of age, and to suffer from obesity, chronic hypertension, pregestational diabetes and thyroid disease. The cancer group had a lower rate of spontaneous vaginal delivery (aOR 0.2, 95 % CI 0.13-0.27, p<0.001), and a higher rate of preterm delivery (aOR 1.85, 95 % CI 1.21-2.82, p=0.04), and of maternal complications such as blood transfusion (aOR 24.7, 95 % CI 17.11-35.66, p<0.001), disseminated intravascular coagulation (aOR 14.56, 95 % CI 3.56-59.55, p<0.001), venous thromboembolism (aOR 9.4, 95 % CI 2.3-38.42, p=0.002) and maternal death (aOR 8.02, 95 % CI 2.55-25.34, p<0.001). Neonatal outcomes were comparable between the two groups.

CONCLUSIONS

Women with a diagnosis of GIS cancer in pregnancy have a higher incidence of maternal complications including maternal death, without any differences in neonatal outcomes.

Diagnosis and Treatment of Metastatic Colon Cancer in Pregnancy First Presenting as Multiple Liver Masses: A Case Report

Colorectal cancer (CRC) is the second most common cancer in women in Japan. However, it is uncommon during pregnancy. CRC diagnosis during pregnancy is often complicated and delayed due to the overlapping of symptoms, such as abdominal pain and nausea, with those of pregnancy and the limitations placed on potential diagnostic imaging and testing because of concerns for the fetus. A 39-year-old woman was referred from a local hospital at 32 weeks gestation after persistent right abdominal pain, which prompted an ultrasound that showed multiple liver lesions suggestive of malignancy. A combination of non-contrast computed tomography, non-contrast magnetic resonance imaging, contrast-enhanced ultrasound, and colonoscopy was utilized to make a definitive diagnosis; ultimately, colonoscopy confirmed the diagnosis of colon cancer with liver metastasis. A discussion within a multidisciplinary team led to the decision to deliver at 34 weeks by cesarean section and a left hemicolectomy was performed after delivery. The neonate was admitted to the neonatal intensive care unit due to prematurity but had no other complications. Chemotherapy was promptly initiated, and treatment was continued on an outpatient basis. Diagnostic algorithms for CRC during pregnancy are not yet well-established; however, the prognosis of CRC during pregnancy is poor, and clinicians should not hesitate to perform the necessary testing and consult experts in fields such as neonatology, medical oncology, internal medicine, and gastrointestinal surgery. Early diagnosis and intervention are essential for optimizing outcomes for both the mother and the fetus.

Maternal and perinatal outcomes of pregnant patients with colorectal cancer: a population-based study

PURPOSE

This study aimed to investigate the maternal and perinatal outcomes of pregnant patients with CRC using a large population-based database.

METHODS

A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS) from 2009 to 2019. Pregnant patients with and without CRC were compared for demographic characteristics, comorbidities, maternal and perinatal outcomes, and hospital burden.

RESULTS

The study included 306 pregnancies with CRC and 40,887,353 pregnancies without CRC. Pregnant patients with CRC were older and more likely to be White. A significant association was observed between CRC and a history of inflammatory bowel disease or a family history of gastrointestinal cancer. Pregnant patients with CRC had higher odds of maternal death (AOR 260.99, 95% CI 33.36-2041.64), cardiac arrhythmia (AOR 13.73, 95% CI 4.21-44.76), acute kidney injury (AOR 32.6, 95% CI 5.29-200.77), severe sepsis (AOR 163.98, 95% CI 22.05-1219.65), and respiratory failure (AOR 31.67, 95% CI 4.11-243.98). Furthermore, the CRC group experienced higher odds of cesarean section (AOR 1.78, 95% CI 1.05-3.03), preterm birth (AOR 4.16, 95% CI 2.05-8.47), and intrauterine death (AOR 13.18, 95% CI 3.33-52.16). Distinct differences in maternal and perinatal outcomes were observed based on the location of CRC. Pregnant patients with CRC faced higher hospital charges and had longer hospital stays during delivery hospitalization compared to those without CRC.

CONCLUSION

Pregnant patients with CRC are at increased risk for adverse maternal and perinatal outcomes, emphasizing the importance of early detection, timely intervention, and comprehensive management during pregnancy.

A Review of the Literature, the Detection and Treatment of Colorectal Cancer during Pregnancy: A Case Study!

Background

Colorectal cancer (CRC) during pregnancy is rare and presents diagnostic and therapeutic challenges.

Aim

This case report focuses on a patient who presented with colorectal cancer during pregnancy.

Case description

A 45-year-old female primigravid, pregnant woman, in the 20th week of gestation presented with complaints of multiple episodes of bloody diarrhea and tenesmus for the past 3 weeks. This was accompanied by poor appetite and weight loss (15 kg) since the onset of pregnancy. The patient also complained of lower back and abdominal pain. Investigations confirmed an obstructing rectosigmoid mass (15 cm) that could not be passed. The patient's pregnancy was terminated, and chemotherapeutic treatment was initiated.

Clinical significance

With the clinical manifestations of CRC during pregnancy being non-specific, tumors are usually discovered at an advanced stage. This poses a challenge for physicians to treat such cases. This case contributes to the growing literature on pregnancies complicated by CRC and highlights the importance of high clinical suspicion and the need for a multidisciplinary team in tailoring treatment regimens in accordance with patient-centered care.

Conclusion

This case report highlights the rarity of colorectal cancer during pregnancy and the challenges faced in the diagnoses and treatment.

How to cite this article

Saeed MF, Almubarak T, Khalaf S, et al. A Review of the Literature, the Detection and Treatment of Colorectal Cancer during Pregnancy: A Case Study! Euroasian J Hepato-Gastroenterol 2023;13(2):159-162.

Clinical advances: pregnancy in gastroenterologic and hepatic conditions

The fields of gastroenterology and hepatology, along with endoscopic practice, have seen significant changes and innovations to practice in just the past few years. These practice changes are not limited to gastroenterology, but maternal fetal medicine and the care of the pregnant person have become increasingly more sophisticated as well. Gastroenterologists are frequently called on to provide consultative input and/or perform endoscopy during pregnancy. To be able to provide the best possible care to these patients, gastroenterologists need to be aware of (and familiar with) the various nuances and caveats related to the care of pregnant patients who either have underlying gastrointestinal (GI) conditions or present with GI and liver disorders. Here, we offer a clinical update with references more recent than 2018, along with a few words about SARS-CoV-2 infection and its relevance to pregnancy.

Gastrointestinal malignancies in pregnancy

Gastrointestinal malignancies, though uncommon in pregnancy, present several unique challenges with regards to diagnosis, staging, and treatment. Imaging the pregnant patient with a suspected or confirmed GI malignancy requires modifications to the radiologic modality of choice and protocol in order to minimize harm to the fetus, ensure accuracy in diagnosis and staging and guide treatment decisions. In this review article, we discuss the imaging approach to the pregnant patient with GI cancer, including safe radiologic modalities and modifications to imaging protocols. We also review the most common GI cancers encountered in pregnancy, including colorectal, pancreatic, gastric, and small bowel tumors, with emphasis to imaging findings, staging, and treatment considerations.

Rare cause of deranged liver profile in pregnancy

We present the case of a 33-year-old pregnant woman with an abnormal liver profile secondary to liver metastases from colon cancer. The patient presented in her third trimester with non-specific symptoms. Blood tests revealed a cholestatic liver picture, initially attributed to prurigo gravidarum. However, following a normal vaginal delivery, her symptoms persisted and the liver profile failed to return to baseline. This led to further investigations including a CT scan of the abdomen-revealing a transverse colonic tumour with extensive liver involvement. Biopsy of the liver confirmed an adenocarcinoma of colonic origin, and subsequently the patient underwent a right hemicolectomy followed by systemic chemotherapy.

Colorectal cancer during pregnancy or postpartum: Case series and literature review

Background

Colorectal cancer in young adults is on the rise. This rise combined with delayed childbearing increases the likelihood of colorectal cancer diagnosed during pregnancy or in the postpartum period.

Methods

Electronic health records were used to identify individuals with colorectal cancer in pregnancy or the postpartum period from 1 August 2007 to 1 August 2019.

Results

Forty-two cases were identified. Median age at diagnosis was 33 years. Most (93%) were diagnosed in an advanced stage (III or IV) and had left-sided colorectal cancer tumors (81%). Molecular analysis was completed in 18 (43%) women with microsatellite status available in 40 (95%). The findings were similar to historical controls. Sixty percent were diagnosed in the postpartum period. Common presenting symptoms were rectal bleeding and abdominal pain.

Conclusion

Currently there is no consensus recommendation regarding how to manage colorectal cancer during pregnancy. Given the overlapping symptoms with pregnancy, patients often present with advanced disease. We encourage all health care professionals caring for pregnant women to fully evaluate women with persistent gastrointestinal symptoms to rule out colorectal cancer.

Multidisciplinary Management of Cancer During Pregnancy

Cancer during pregnancy is relatively rare but is increasing in frequency in countries in which the maternal child-bearing age continues to rise. The complexities of medical decision making are underscored by the need to weigh the potential benefits of any intervention for the mother against the risks to the fetus. A majority of diagnostic evaluations can be performed safely in the setting of pregnancy and should not be delayed. Noninvasive prenatal testing that shows discordance with fetal karyotype can be a clue to an underlying maternal malignancy. After diagnosis, a multidisciplinary team should formulate a care plan for both the mother and the fetus. Key topics for discussion should include the mother's prognosis, standard treatment plan, and predictions of how modifications for a continuing pregnancy will affect the treatment plan and overall prognosis. In the context of this knowledge, frank discussions about pregnancy termination should be addressed with the patient, if appropriate. Selection of a plan for oncologic management in the case of a pregnant woman is based on the type of cancer, the tumor biology, and the tumor stage. Additional complexities for pregnant patients are typically related to the gestational age of the fetus, the dynamic physiologic changes of pregnancy, and the limited safety data for administration of most anticancer therapies during pregnancy. In this article, we summarize data related to different classes of anticancer therapies as well as considerations for the management of selected cancers. Finally, we provide some key principles that should be considered in the management of patients with cancer during pregnancy.

MRI in pregnant patients with suspected abdominal and pelvic cancer: a practical guide for radiologists

The incidence of abdominal and pelvic cancer in pregnancy is low, but it is rising as the population of pregnant women gets older. Depending on disease stage, gestational age and patient's preference, active surveillance as well as surgery and chemotherapy are feasible options during pregnancy. Correct diagnosis and staging of the tumor is crucial for choosing the best therapeutic approach. Moreover, a reproducible modality to assess the treatment response is requested. Magnetic resonance imaging (MRI) is commonly used with good results for the local staging and treatment response evaluation of most abdominal and pelvic cancers in nonpregnant patients, and it is considered relatively safe during pregnancy. The purpose of this article is to analyze the most relevant topics regarding the use of MRI in pregnant women with abdominal and pelvic cancer. We discuss MRI safety during pregnancy, including the use of gadolinium-based contrast agents (GBCAs), how to prepare the patient for the exam and MRI technique. This will be followed by a brief review on the most common malignancies diagnosed during pregnancy and their MRI appearance.

Colon Adenocarcinoma during Pregnancy: A Case Report and Review of the Literature

Colorectal cancer (CRC) during pregnancy presents an estimated incidence of 1 : 13,000, and it is associated with diagnostic and therapeutic challenges. Here, we present the case of a 38-year-old woman, 25 weeks and 5 days pregnant, who was transferred to our Obstetrics and Gynecology Department from a local hospital with the diagnosis of intestinal obstruction. Magnetic Resonance Imaging (MRI) showed marked distension with hydroaerial levels of the enterocolic loops upstream of a concentric parietal thickening of the descending colon, stenosing, extended longitudinally for about 4 cm. An exploratory laparotomy was performed with resection of the colon splenic flexure and mechanical end-terminal anastomosis. Histological examination of the operating piece highlighted the presence of moderately differentiated (G2) colon adenocarcinoma (stage pT3N1b). The operation was followed by a single course of oxaliplatin and 5-FU plus leukovorin. The patient had a vaginal delivery at 37 weeks + 2 days of gestational age, following induction of labor and giving birth to a male infant whose weight was 2670 gr with apgar 9/9. We underline the pivotal role of attention to unspecific symptoms, early diagnosis, and active treatment in changing the clinical course of CRC.

Colorectal cancer in the setting of pregnancy and familial risk

BACKGROUND AND AIMS

Women are at risk of colorectal cancer (CRC) during pregnancy but this fact is underappreciated. We performed a population-based study to evaluate the rate, predictors, and familial risk for pregnancy associated CRC in Utah.

METHODS

All newly diagnosed cases of CRC between 1973 and 2014 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database.

RESULTS

Of the 12,886 females diagnosed with CRC, 73 were diagnosed with CRC (0.57%) during the period of obstetric delivery/childbirth. Pregnancy associated CRC was diagnosed at a mean age of 31.9 years, and cancers were less frequently located in the proximal colon compared with women with non-pregnancy associated CRC. First-degree relatives of cases with pregnancy associated CRC had a nearly threefold higher risk of CRC (OR, 2.76; 95% CI, 1.26-6.01) compared with relatives of CRC-free individuals.

CONCLUSIONS

Of women diagnosed with CRC, less than 1% were diagnosed during or soon after obstetric delivery/childbirth. Relatives of these patients have a nearly threefold greater risk of CRC than those without a family history of CRC. These results provide physicians with data to guide the care of patients and their relatives with pregnancy associated CRC.

Adenocarcinoma of Sigmoid Colon Diagnosed in Pregnancy: A Case Report

With more women getting pregnant at later ages than in the past, the incidence of malignancies in pregnancy is on the rise. Common malignancies of pregnancy are melanoma, breast cancer, cervical cancer, lymphomas, and leukemias. Colorectal carcinoma is rare in pregnancy, with an estimated incidence of 1 in 13',000 cases. We describe such a case of colorectal carcinoma in pregnancy (CRC-p), in a 31-year-old patient. She presented in the 21^st week of her second pregnancy with constipation of two weeks duration despite appropriate medical management. This prompted further evaluation with abdominal imaging revealing partial small bowel obstruction of unclear etiology. She was treated surgically with subtotal colectomy with ileostomy. Pathologic evaluation revealed Stage III B: pT3N2a adenocarcinoma with mucinous features of the sigmoid colon with lymph node metastases. Adjuvant FOLFOX chemotherapy was started in the third trimester and was continued postpartum for a total of 12 cycles. She is doing well, and ileostomy reversal is being planned at the time of writing this. Advancing maternal age is a significant risk factor for CRC-p. Common presenting symptoms in CRC-p include bleeding per rectum, abdominal pain, vomiting, and constipation. The frequent occurrence of many of these symptoms, as well as risks and restrictions associated with diagnostic modalities such as computed tomography scan and colonoscopy during pregnancy, makes the diagnosis challenging. Colonoscopy, followed by pathology evaluation, remains the standard diagnostic method in CRC-p. Management of CRC-p is determined by multiple variables such as the stage of the disease, gestational age, and most importantly, patient wishes. Surgical resection is performed following the diagnosis if the gestational age is less than 20 weeks and delayed until after delivery if gestational age is above 20 weeks. 5-fluorouracil based chemotherapy regimens are used in second and third trimesters, in patients with stage III CRC-p. Prognosis has been reported variably. Despite advanced stages at presentation, most of the studies indicate a similar prognosis compared to CRC in the non-pregnant population. Two-year survival was found to be 64.4% in one case series.

Colorectal Signet Ring Cell Carcinoma in a Young Pregnant Woman

Colorectal cancer during pregnancy is one of the less common neoplasms with an incidence of 0.8 in 100,000 pregnancies. Primary colonic signet ring cell carcinoma is a weird variety, characterized by a poor histologic differentiation, with a high morbidity-mortality rate. The case of a 24-year-old patient with a 22-week-old pregnancy and colorectal cancer stage IV in palliative state is presented, with a devastating result. Early diagnosis represents a challenge because of the presentation form and the histologic aggressiveness of this disease. We suggest that colorectal cancer during pregnancy must be treated by a multidisciplinary team.

Oncological outcome of peripartum colorectal carcinoma-a single-center experience

OBJECTIVES

This study aimed to analyze disease presentation, management, and oncological outcomes of patients diagnosed with peripartum colorectal cancer (CRC).

METHODS

Retrospective cohort study of all consecutive women of childbearing age (18-45 years) between 2002 and 2014 diagnosed with CRC adenocarcinoma at a tertiary academic institution. Patients who experienced pregnancy within 12 months of their diagnosis (peripartum period, group 1) were compared to the remaining patients of the cohort (group 2). Overall survival (OS) was compared between the two groups through Kaplan-Meier estimates.

RESULTS

Out of 555 consecutive women with a mean age of 37.8 + 6 years, 31 (5.6%) were diagnosed with CRC in the peripartum period. Of these, all patients were symptomatic during pregnancy due to bleeding, abdominal pain, or constipation; however, only 11 CRC (35.5%) were diagnosed during pregnancy, 1 (3.2%) during C section, and the remaining (61.3%) postpartum. TNM stage at presentation was I in 6 patients (19.4%), II in 4 patients (13.9%), III in 8 patients (25.8%), and IV in 13 patients (41.9%). Surgical resection was performed in 23 patients (74.2%): 2 while pregnant, 2 at the time of C section, and the remainder postpartum. Across all stages, OS was 95% at 1 year and 62% at 5 years and did not differ between the two comparative groups (p = 0.16).

CONCLUSIONS

A suspicious attitude towards cancer-related symptoms during pregnancy is crucial to prevent delayed evaluation for CRC.