Management of appendiceal pseudomyxoma peritonei diagnosed during pregnancy

Management of mucocele of the appendix with peritoneal dissemination in pregnant women: a case report and literature review

BACKGROUND

This is the first case report of a patient with a twin pregnancy who developed appendiceal mucocele (AM) with peritoneal dissemination in the context of endometriosis and ovarian hyperstimulation. A review of the literature on AM during pregnancy, with a focus on management, is provided as well.

CASE PRESENTATION

A 36-year-old woman was admitted to the emergency department for abdominal pain in the right iliac fossa at 17 weeks of amenorrhoea (WA). She was pregnant with twins, achieved by in vitro fertilisation (IVF) and complicated by ovarian hyperstimulation syndrome. Abdominal ultrasonography indicated a diagnosis of uncomplicated acute appendicitis. However, the histopathological findings revealed low-grade appendicular mucinous neoplasia (LAMN) with peritoneal dissemination of acellular mucin. Maximal cytoreductive surgery with hyperthermic intraperitoneal mitomycin chemotherapy was performed post-partum.

CONCLUSIONS

Specialised management is required for AM during pregnancy and must take into account the progress of the pregnancy, the histology of the AM and the risk of perforation.

Management of peritoneal pseudomyxoma in Pregnant Women: A case report and review of the literature

The incidence of neoplasia during pregnancy is low, 1/1000 pregnancies. The most common cancers diagnosed during pregnancy are breast and cervical cancer. Pseudomyxoma peritonei (PMP) is a rare syndrome (1/1 000 000) characterized by the presence of gelatinous ascites and disseminated intra-peritoneal mucinous tumors. The origin of this syndrome is, in most of cases, a tumor of the appendix. A PMP diagnosis during pregnancy is an extremely rare event. We present the medical history of a 34-year-old woman diagnosed with a PMP at 29 weeks of amenorrhea, during the management of an ovarian masse. We preserved the pregnancy until 37 weeks of amenorrhea. She had a vaginal delivery. At 4 weeks post-partum, she had an extensive cytoreduction with intraperitoneal chemotherapy. We present literature review of PMP discover during pregnancy and a discussion about treatment of these PMP. We also discuss management of an ovarian masse diagnosis during pregnancy.

Multicystic peritoneal mesothelioma treated with cytoreductive surgery followed or not by hyperthermic intraperitoneal chemotherapy: results from a large multicentric cohort

BACKGROUND

Multicystic peritoneal mesothelioma (MCPM) is a rare, slowly growing, condition prone to recur after surgery. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) added to complete cytoreductive surgery (CRS) remains controversial and difficult to assess. As patients are mostly reproductive age women, surgical approach, and fertility considerations are important aspects of the management. This observational retrospective review aimed to accurate treatment strategy reflections.

METHODS

The RENAPE database (French expert centers network) was analyzed over a 1999-2019 period. MCPM patients treated with CRS were included. A special focus on HIPEC, mini-invasive approach, and fertility considerations was performed.

RESULTS

Overall 60 patients (50 women) were included with a median PCI of 10 (4-14) allowing 97% of complete surgery, followed by HIPEC in 82% of patients. A quarter of patients had a laparoscopic approach. Twelve patients (20%) recurred with a 3-year recurrence free survival of 84.2% (95% confidence interval 74.7-95.0). The hazard of recurrence was numerically reduced among patients receiving HIPEC, however, not statistically significant (hazard ratio 0.41, 0.12-1.42, p = 0.200). A severe post-operative adverse event occurred in 22% of patients with five patients submitted to a subsequent reoperation. Among four patients with a childbearing desire, three were successful (two had a laparoscopic-CRS-HIPEC and one a conventional CRS without HIPEC).

CONCLUSION

MCPM patients treatment should aim at a complete CRS. The intraoperative treatment options as laparoscopic approach, fertility function sparing and HIPEC should be discussed in expert centers to propose the most appropriate strategy.

Management of Low-Grade Appendiceal Mucinous Neoplasm with Extensive Peritoneal Spread Diagnosed during Pregnancy: Two Case Reports and Literature Review

BACKGROUND

Clinical decisions in patients with peritoneal dissemination of low-grade appendiceal mucinous neoplasms (LAMN) diagnosed during pregnancy are challenging. However, their slow progression and favorable prognosis allow deferring definitive treatment until after spontaneous delivery, a reasonable period of breastfeeding, and fertility preservation. Case Presentation. Two pregnant patients were incidentally diagnosed with LAMN and extensive peritoneal spread at 20 weeks gestation and at cesarean section. Treatment with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in both cases was delayed until spontaneous delivery at term and breastfeeding in the first patient and breastfeeding and fertility preservation in the second patient. Both patients remain disease-free for over 5 years, and their children are healthy. The literature review highlights the challenges that physicians face in treating pregnant patients with stage IV appendiceal tumors.

CONCLUSION

Pregnancy management decisions in patients with peritoneal spread from mucinous appendiceal tumor should be based on understanding the tumor biology and prognosis. Definitive treatment in pregnant patients with favorable tumors, such as LAMN, may be delayed until spontaneous delivery without compromising maternal survival.

Incidental low grade mucinous neoplasm of appendix in pregnancy: A case report & literature review

Introduction

Mucinous neoplasms of appendix account for 0.2–0.4% of all the appendix specimens. The occurrence of this neoplasm in pregnancy is extremely rare. We describe a case of a pregnant lady who was diagnosed as acute appendicitis and found to have Low-Grade Mucinous neoplasm on histopathology. In the existent literature, there are only a few such cases reported and none from our Middle East region.

Case presentation

42-year-old pregnant lady at 24 weeks of gestation presented with classical symptoms of acute appendicitis. She had leukocytosis but the Ultrasound was equivocal. She underwent laparoscopic appendectomy and found to have an inflamed appendix. Postoperative recovery was satisfactory and was discharged home. The histopathology report showed low-grade mucinous neoplasm of the appendix and she was detailed about it on follow up.

Discussion

The incidence of appendiceal neoplasm is rare in routine appendectomy and carcinoid is the most common tumor of the appendix. Low-Grade mucinous neoplasm is a rare entity and its presence in pregnancy is further rarer.

Conclusion

Since this neoplasm does not manifest with a characteristic clinical profile it is difficult to diagnose, even with extensive preoperative evaluation. Although surgical treatment is straight forward, the management of the appendiceal neoplasm during pregnancy necessitates full knowledge of the natural history of the disease to attain equilibrium of concern for maternal survival and fetal health.

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Mucinous neoplasms of appendix are known to be rarely found in all the appendix specimens, but the occurrence of this neoplasm in pregnancy is extremely rare.

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This neoplasm does not manifest with distinctive clinical profile and it is challenging to diagnose it, even with extensive preoperative evaluation.

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It is questionable to decide whether to allow pregnancy or terminate unless proper work up is not done to decide the nature of this neoplasm.

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Further studies dedicated to the understanding of the mucinous neoplasms can help us with designing a more targeted therapeutic plan for such patients.

A comprehensive review of childbearing after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

PURPOSE

Our aim is to present a review on childbearing following CRS and HIPEC for peritoneal malignancy.

METHODS

A review of the English literature, up to December 2019, was conducted, using PubMed/MEDLINE, EmBase and Google Scholar bibliographic databases, following the MOOSE guidelines. The terms "Cytoreductive Surgery", "Hyperthermic Intraperitoneal Chemotherapy", "Peritoneal Carcinomatosis", "Pregnancy", "Fertility Preservation", "Conception" were used. All study designs were eligible for inclusion in the final analysis.

RESULTS

In total, 7 studies (5 case reports and 2 case series) were included in the final analysis, reporting on 14 successful pregnancies after CRS and HIPEC. The mean age of patients at the time of CRS/HIPEC was 28.8 ± 5.9 years (range 18-36), while the mean interval between CRS/HIPEC and pregnancy was 29.6 ± 20.3 months (range 9-80 months). Nine patients were treated for pseudomyxoma peritonei, four for primary peritoneal mesothelioma and one for endocrine carcinoma. Mean Peritoneal Carcinomatosis Index was 9.8 ± 7.8 (range 1-26). All patients underwent fertility-sparing CRS (preservation of at least one ovary and the uterus). In 12 cases, conception was spontaneous, whereas two pregnancies were achieved through in-vitro fertilization. One patient developed gestational hypertension, while two labors were preterm. Mean disease-free survival was 64.1 months (range 24-106 months).

CONCLUSION

A successful pregnancy is feasible in selected patients, after CRS and HIPEC. Assisted reproduction techniques (IVF using frozen oocytes or frozen embryos, ovarian tissue cryopreservation, preoperative treatment with GnRH analogs) should be discussed pre-operatively with the patient, without, however, compromising overall survival or risking locoregional recurrence.

An incidental finding of low-grade appendiceal mucinous neoplasm during cesarean section: A case report

Low‐grade appendiceal mucinous neoplasms are rare and difficult to diagnose preoperatively because of a lack of characteristic symptoms. A 24‐year‐old female with no symptoms before pregnancy underwent an elective cesarean section at 38 weeks of gestation because of cephalo‐pelvic disproportion. Although no abnormalities were detected in the newborn, uterus, or uterine adnexa, a sausage‐like, swollen appendix was noted. The patient underwent appendectomy. Pathology showed the tumor was a low‐grade appendiceal mucinous neoplasm.

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.

A case of pulmonary carcinoid tumour in a pregnant woman successfully treated with bronchoscopic (electrocautery) therapy

We present an uncommon case of a carcinoid tumour of the bronchus that was diagnosed during pregnancy in a 28-year-old woman. The patient was admitted at the emergency department with massive haemoptysis. Owing to the patient's critical condition, she underwent urgent flexible bronchoscopy. Bleeding was controlled by local injection of 500 mg tranexamic acid and electrocautery. After the bleeding has stopped, multiple specimens were taken. Histological examination confirmed typical carcinoid tumour. Owing to repeated haemoptysis, she was treated with bronchoscopic (electrocautery) therapy, and, after delivery, she underwent pulmonary lobectomy. Only a few similar cases were found in the literature reporting bronchopulmonary carcinoid tumour during pregnancy and we could not find any similar case which was treated by electrocautery.

Case study of appendiceal carcinoid during pregnancy

The carcinoid tumor of the appendix is one of the most common tumors of the appendix, but one of the rarest anatomic locations of carcinoids. The prognosis is very good, as most tumors are incidentally discovered during surgery for acute or sub-acute appendicitis. The diagnosis is exceptional when combined with pregnancy. We present such a case of a 27-year-old female patient. An emergency appendectomy was performed, and soon after, pregnancy was confirmed. The patient had a tumor smaller than 1 cm in diameter, at the tip of the appendix. The immunochemistry revealed the neuroendocrine profile by positive reaction for chromogranin A and synaptophysin, with a ki-67 profile at an undetectable level. After surgery, the neuroendocrine markers and the octreoscan were negative, consequently indicating a favorable prognosis. Further follow-up is necessary, even though not all the authors recommend it (considering the low index to the associated metastases, especially for small appendiceal tumors). A short review of the literature is presented, starting with this case report.

Childbearing after hyperthermic intraperitoneal chemotherapy: results from an international survey

BACKGROUND

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) can improve survival in selected patients with primary or secondary peritoneal malignancies. With the opportunity for long-term survival, questions about the impact of those procedures in fertility in women of childbearing age can be raised.

MATERIALS AND METHODS

An international survey was performed among all teams participating in the International Peritoneal Surface Malignancy Group in order to collect data about pregnancies and their outcome in women having undergone previous CRS with adjuvant HIPEC.

RESULTS

There were 7 pregnancies reported after CRS and HIPEC in women treated for peritoneal malignancies. All these women conceived spontaneously, most of them within 2 years after the procedure. They delivered most often by vaginal way after an uneventful pregnancy. Their newborns were healthy, except 1 case of congenital diaphragmatic hernia requiring emergent surgery. There were 2 additional uneventful pregnancies reported after the diagnosis of pseudomyxoma peritonei and before CRS and HIPEC, with the support of the medical team. Another woman having undergone oocytes retrieval and embryo cryopreservation prior to the surgery was mother of twins after the procedure via a surrogate mother.

CONCLUSION

Childbearing after cytoreductive surgery and heated intraperitoneal chemotherapy is possible in women conserving their genital organs after the procedure. The question of fertility should be considered and discussed in women in reproductive age prior to cytoreductive surgery and heated intraperitoneal chemotherapy. Different options could be offered in this setting. Multidisciplinary decision making involving surgical oncologists and fertility specialists is important.

Pseudomyxoma peritonei originating from colorectal cancer during pregnancy

Pseudomyxoma peritonei is an extremely rare condition characterized by the presence of gelatinous ascites and disseminated intra-peritoneal mucinous tumors. To our knowledge, there have been only two case reports of pseudomyxoma peritonei during pregnancy in 2009, both of which originated from the appendix. We present the first case of pseudomyxoma peritonei originating from colorectal cancer during pregnancy. Prenatal ultrasound examination of a 34-year-old, asymptomatic woman revealed characteristic features of pseudomyxoma peritonei at 24 weeks gestation. At laparotomy, both ovaries were involved with copious amounts of mucinous tumors and fluid, an advanced colorectal cancer had invaded the peritoneal cavity and multiple disseminated tumors were noted around the intraperitoneal cavity. All clinicians practicing obstetrics and gynecology must consider the possibility of a malignant neoplasm presenting in a pregnant woman and should recognize the highly characteristic features of pseudomyxoma peritonei to enable detection of this rare condition incidentally during routine screening ultrasound examinations.