Year : 2021 | Volume
: 4 | Issue : 2 | Page : 78--80
A case of colorectal cancer in pregnancy
PM Gopinath, Susan Mathen, E Esther Rani Stella Bhakiyathai
Department of Obstetrics, Gynaecology and IVF, SRM Institutes For Medical Sciences, Chennai, Tamil Nadu, India
P M Gopinath
Department of Obstetrics, Gynaecology and IVF, SRM Institutes for Medical Sciences, No. 1 Jawaharlal Nehru Road, Next to Vadapalani Metro, Chennai 600026, Tamil Nadu
Colorectal cancer in pregnancy is a rare pathology with limited high-grade evidence available. The diagnosis of colorectal cancer in pregnancy is delayed and has a varied presentation, which may mimic pregnancy. Challenges exist as the treatment options are delayed and a decision needs to be made encompassing both mother and fetus.
|How to cite this article:|
Gopinath P M, Mathen S, Stella Bhakiyathai E E. A case of colorectal cancer in pregnancy.Onco Fertil J 2021;4:78-80
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Gopinath P M, Mathen S, Stella Bhakiyathai E E. A case of colorectal cancer in pregnancy. Onco Fertil J [serial online] 2021 [cited 2023 Mar 22 ];4:78-80
Available from: https://www.tofjonline.org/text.asp?2021/4/2/78/366156
Colorectal cancer (CRC) in pregnancy is a rare pathology and has limited evidence available with an incidence of 0.8 per 100,000 pregnancies with advanced disease (stage III or IV) being diagnosed more frequently in pregnant patients. A significant overlap in symptoms occurs and hence the diagnosis is delayed. The overall prognosis is poor with a 5-year survival rate ranges from 0% to 42%.
CRC is the third most common type of cancer with an increase in incidence in younger patient (<40 years). It is the seventh most common type of cancer in pregnancy. Most CRC in pregnancy are an aggressive mucinous subtype, with poorer prognosis. Primary signet-cell carcinoma (SRCC) of the colon and rectum presents in the younger age with a rare incidence of >0.1% of cases of CRC in pregnancy.
Environmental factors, genetic predisposition and advanced maternal age play a dominant role in the etiology. Lynch’s syndrome (herediatary non polyposis colorectal cancer-HNCC) and familial adenomatous polyposis (FAP) are both inherited autosomal dominant syndromes which can causes cancers at an early age. When discovered during pregnancy, two-thirds of CRC in women tend to involve the rectum and sigmoidcolon. 85% of CRC in pregnancy are below the peritoneal reflection. FAP is a known risk factor for CRC during pregnancy. Genetic testing is only recommended for those with a family history suggestive of Lynch syndrome. 30% of tumors have microsatellite instability in pregnant women with SRCC.
Patients who present may be asymptomatic with normal fetal movements or may have nausea, vomiting, and abdominal pain, weight loss, anemia, altered bowel habits and rectal bleeding. Carcinoembryonic antigen of 10 µg/L during pregnancy should be investigated. Ultrasound evaluation can be used to detect hepatic metastases but due to the gravid uterus it has limited accuracy. Thoraco-abdomino-pelvic computed tomography (CT) scan, magnetic resonance imaging (MRI) and colonoscopy is relatively contraindicated in first trimester of pregnancy, but can be done. Flexible rectosigmoidoscopy without sedation is an alternative as most cases are confined to distal colon.
Treatment modalities include surgery, chemotherapy and radiation therapy depending on the stage of the cancer. Cancer per se is not an indication for caesarean section. The liver is the most common site for metastases followed by the ovary. Pregnant women with CRC have a poor prognosis usually due to widespread metastasis, but their 5-year survival rate is the same.
A 27-year-old primigravida came to the hospital for her first antenatenatal checkup at 23 weeks of gestation. On examination, she was found to be pale with no other significant findings. Her Placental growth factor was found to be elevated for which she was started on low-dose aspirin oral medication. Her hemoglobin was found to be low even after oral medications and hence given intravenous iron therapy. She complained of persistent back pain all through her pregnancy for which initially she was reassured. As her pregnancy progressed back pain increased and she had difficulty on lying down and movement, hence orthopedic and neurologic opinion was taken and advised for postnatal follow-up. In her third trimester, she had two to three episodes of blood tinged loose stool associated with fever, which was conservatively managed and aspirin was stopped. All antenatal scans were found to be normal with no significant findings. She had a weight gain of 6–7 kg all through her pregnancy with no other gastrointestinal symptoms or signs. She presented at 38 weeks of gestation with complaints of leaking per vaginum in January 2022 and was found to have cephalopelvic disproportion and hence taken up for emergency lower segment Cesarean section. She delivered a live term female of weight 2.56 kg with APGAR 8/10 9/10.
Utero-vaginal fold, peritoneum, anterior, and posterior uterine walls were studded with tubercle-like lesions.
Hard mass measuring approximately 8 cm x 6 cm was seen involving the sigmoid colon and biopsy was taken from the lesion and sent for histopathology.
On post-operative day 1 abdomen was distended with sluggish bowel sounds and nil per oral continued and ryle’s tube drainage done. Post-operative day 2 distension subsided and she passed motion and so was started orally. Sigmoidoscopy showed circumferential ulceroproliferative friable growth with significant luminal narrowing. Colonoscopic biospsy from rectosigmoid confirmed mucinous adenocarcinoma grade II–III with signet ring morphology. Immunohistochemistry was done which was suggestive of mucinous metastatic adenocarcinoma, colorectal origin (CK20 and CDX2––positive). In February 2022, she underwent diagnostic laparoscopy, which was suggestive of peritoneal involvement of the carcinoma. She had postoperative cardiomyopathy for which she was managed in the intensive care unit and revived successfully. She was then started on chemotherapy and completed six cycles of chemotherapy––CAPOX (Capecitabine, Oxaliplatin, Panitumumab, Zolendronic acid) regimen. Positron emission tomography scan done after second and fourth course of chemotherapy suggests stable disease.
Histopathology, immunohistochemistry taken during lower segment Cesarean section––January 2022––metastatic adenocarcinoma suggestive of colorectal origin, positive for CDX2 and CK20.
Positron emission tomography-CT––January 2022: distal sigmoid colon and upper one-third of rectum 9 cm × 1.6 cm lesion seen from 16 cm from anal verge. Perirectal plane infiltrated, mesorectal, and presacral lymph node involved. Bilateral pleural effusion.
Histopathology from Sigmoidoscopy in February 2022––mucinous adenocarcinoma, grade 2 with signet ring morphology.
CRC is rare in pregnancy but its incidence is increasing. Genetic alterations and environmental factors play a significant role in this disease. Symptoms that are common in both pregnancy and CRC make it difficult to distinguish the two. Management should be individualized and should include the gestational age, fetal maturity and the cancer stage. In the first 20 weeks of pregnancy, pregnancy may need to be terminated and early cancer treatment should be started. After 20 weeks of pregnancy, the treatment is less well defined. Surgery may be delayed and can be done right after an uncomplicated cesarean section. Placenta should be examined for metastases. Chemotherapy is associated with intrauterine growth retardation and prematurity., CRC is an aggressive cancer that is rarely found in pregnancy, but when diagnosed it usually has a poor outcome. A multidisciplinary approach is required for the treatment of the same and to decide the fate of pregnancy and fetus.
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Conflicts of interest
There are no conflicts of interest.
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