- Email: [email protected]
Rectal cancer in pregnancy: A diagnostic and therapeutic challenge
Journal of the Egyptian National Cancer Institute (2014) xxx, xxx–xxx
Cairo University
Journal of the Egyptian National Cancer Institute www.nci.cu.adu.eg www.sciencedirect.com
Case Report
Rectal cancer in pregnancy: A diagnostic and therapeutic challenge Monireh Toosi a, Leila Moaddabshoar b, Seyed Ali Malek-Hosseini c, Mohammad Reza Sasani d, Maral Mokhtari e, Mohammad Mohammadianpanah
f,*
a
Department of Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran Student Research Committee, Resident of Radiation Oncology, Shiraz University of Medical Sciences, Shiraz, Iran c Organ Transplant Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran d Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran e Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran f Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran b
Received 15 February 2014; revised 13 March 2014; accepted 13 March 2014
KEYWORDS Rectal cancer; Pregnancy; Diagnosis; Treatment; Prognosis
Abstract Introduction: The occurrence of colorectal cancer during pregnancy is rare and is associated with diagnostic and therapeutic challenges. Herein, we report such a case of rectal cancer in pregnancy and review the literature. Case report: A 31-year-old multiparous, pregnant woman, in the 20th week of gestation, presented with rectal bleeding progressing to spasmodic abdominal pain and right flank vague pain. A flexible rectosigmoidoscopy showed a large ulcerative mass located in the rectosigmoid junction, 15 cm away from anal verge. Imaging studies and biopsy proved it to be rectal adenocarcinoma with single liver metastasis. The patient’s pregnancy was terminated and neoadjuvant therapy followed by curative surgery was performed. She is currently receiving adjuvant systemic therapy to eradicate potential micrometastatic disease. Conclusion: This case suggests that colorectal cancer can mimic the signs and the symptoms of pregnancy and tends to present at an advanced stage in pregnant women. ª 2014 Production and hosting by Elsevier B.V. on behalf of National Cancer Institute, Cairo University.
* Corresponding author. Address: Colorectal Research Center, Department of Radiation Oncology, Namazi Hospital, Shiraz 7193613511, Iran. Tel./fax: +98 711 6474320. E-mail addresses: [email protected], [email protected] (M. Mohammadianpanah). Peer review under responsibility of The National Cancer Institute, Cairo University.
Production and hosting by Elsevier
Introduction In developing countries, colorectal cancer is the fifth most common cancer in men and third in women [1]. However, the occurrence of colorectal cancer in women under 40 is uncommon and it is very rare during pregnancy [2]. The incidence of cancer in pregnancy ranges from 0.02% to 0.1%. Colorectal cancer is one of the eight most frequent malignant neoplasms in pregnancy [3]. This rare condition is associated with diagnostic and therapeutic challenges [4]. The signs and
1110-0362 ª 2014 Production and hosting by Elsevier B.V. on behalf of National Cancer Institute, Cairo University. http://dx.doi.org/10.1016/j.jnci.2014.03.003 Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
2
M. Toosi et al.
the symptoms of the pregnancy can mask colorectal cancer in a pregnant woman and lead to late diagnosis in advanced stages and poor treatment outcome [5]. In the present study, we report such a case of advanced rectal cancer presented during pregnancy. Case report A 31-year-old multiparous, pregnant woman (gravid 3, para 1), in the 20th week of gestation, presented with a 4-week history of rectal bleeding progressing to spasmodic abdominal pain and right flank vague pain. The patient’s past medical and family history was negative for malignancy. An abdominal and pelvis ultrasound showed an alive single 20th week fetus, wall thickening of rectosigmoid junction and a large single hypoechoic lesion in right posterior liver lobe. A flexible rectosigmoidoscopy showed a large ulcerative lesion in rectosigmoid junction 15 cm to 22 cm away from anal verge. Transrectal biopsy of the rectal lesion revealed well differentiated adenocarcinoma of the rectum (Fig. 1). An ultrasound-guided core needle biopsy of the liver lesion confirmed metastatic rectal adenocarcinoma (Fig. 2). The patient was discussed in a multidisciplinary medical council including specialities of gynecologic oncology, perinatologist, surgical oncology, medical oncology and radiation oncology. Therefore, termination of pregnancy and neoadjuvant chemotherapy and chemoradiation were suggested for the patient’s potentially resectable stage IV rectal cancer. According to the medical council suggestion, as well as the patient’s desire for therapeutic abortion, a computed tomography (CT) scan of the chest, abdomen and pelvis was performed for precise staging. In abdominal and pelvic CT scan, there was a single fetus (Fig. 3), and a locally advanced rectal tumor as significant wall thickening of rectosigmoid junction associated with enlarged perirectal and mesenteric lymph nodes. In addition, there was a large single mass in right posterior liver lobe (Fig. 4). Therefore, the patient’s pregnancy was terminated and 2 weeks later she was referred for neoadjuvant therapies. The patients received a cycle of neoadjuvant chemotherapy consisting of capecitabine 1000 mg/m2 twice daily for 14 of every
Figure 2 Trucut biopsy of the liver which shows involvement by well differentiated adenocarcinoma, H&E, ·100.
Figure 3 Contrast enhanced CT image of the abdomen and pelvis showing a single intrauterine fetus.
Figure 1 Rectosigmoid adenocarcinoma showing well differentiated glands containing atypical cells with high N/C ratio, hyperchromatism and stratification, H&E, ·400.
three weeks cycle, plus oxaliplatin 130 mg/m2 intravenously on day 1 (CAPEOX regimen); followed by concurrent neoadjuvant chemoradiation. Concurrent chemotherapy consists of oxaliplatin 130 mg/m2 intravenously on day 1, plus oral capecitabine 825 mg/m2 twice daily during the whole period of radiotherapy with weekend breaks. Two weeks after
Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
The last patient’s status
Alive with disease 10 months following delivery Alive without disease 12 months following delivery Dead 9 months following delivery Dead 2 weeks after diagnosis Alive without disease 5 years following initial diagnosis Dead 12 months following delivery Dead 4 months following delivery Alive with disease 3.5 years following delivery Alive without disease 23 months following initial diagnosis Alive without disease 8 months following delivery Dead 15 months following surgery Alive without disease 12 months following delivery Alive without disease 18 months following delivery Lost to follow up Dead soon due to brain metastases Alive without disease just following delivery Alive without disease just following delivery
Treatment sequence
3
Abbreviations: CT, Chemotherapy; Del, Delivery; Sur, Surgery; RT, Radiotherapy. a These authors reported 2 cases.
IV II IV IV II IV IV IV III III IV III III IV IV II III
Disease stage Gestational age (week)
19 18 36 21 21 13 23 20 38 27 37 32 32 30 39 38 26 38 35 32 17 29 26 40 25 30 29 30 31 28 25 34 27 32 2013 2013 2012 2012 2012 2011 2009 2009 2009 2007 2005 2005 2005 2003 2003 2000 2000 Dogan [5] Bukhari [11] Hojgaard [16] Araujo Junior [17] Ho [18] Jeppesen [19] Kanate [20] Gensheimer [21] Chourak [22] Lolis [23] Harma [24] Pigeau [25] Pigeau [25]a Ruiz Molina [26] Ruiz Molina [26]a Ochshorn [27] Caforio [28]
Patient’s age Year of publication Authors
There are many challenging issues regarding the diagnosis and management of colorectal cancer in pregnancy [6]. Colorectal cancer can be masked by the signs and the symptoms of the pregnancy. Spasmodic abdominal pain secondary to the partial large bowel obstruction may be considered as normal uterine cramps. As well, anorectal bleeding and pain may be misdiagnosed as a sequence of engorged hemorrhoid or anal fissure [2]. In our patient, occasional rectal bleeding and crampy abdominal pain was misdiagnosed as the signs and the symptoms of normal pregnancy by the patient for a few weeks. There are many limitations and contraindications for using diagnostic tools during pregnancy [7,8]. Colonoscopy and biopsy are golden standard tests for diagnosing colorectal cancer; however, this diagnostic test may complicate pregnancy
Table 1
Discussion
Fifteen reports of rectal cancer in pregnancy between 2000 and 2013.
Figure 4 Contrast enhanced CT image of the abdomen and pelvis showing significant tumoral wall thickening of rectosigmoid junction (white arrow) associated with liver mass (black arrow).
completion of chemoradiation, she received the 3rd cycle of neoadjuvant chemotherapy. Before surgical intervention, a new abdominal and pelvic CT scan showed marked regression of the rectal tumor; however, liver metastasis showed somewhat progression. The patient subsequently underwent staged curative surgical resection of the primary rectal tumor and liver metastasis. Adjuvant chemotherapy combined with targeted therapy using bevacizumab has been considered for the patients to eradicate potential micrometastatic disease.
CT fi Del fi CT Sur fi CT fi Del Sur fi Del fi CT No treatment Sur fi Del fi CT CT fi Del fi CT CT fi Del fi CT Sur fi CT fi Del fi CT Del fi Sur fi RT fi CT Del fi Sur fi RT fi CT Del fi Sur fi CT Del fi RT fi CT Del fi RT fi CT Sur fi Del fi CT Sur fi Del fi CT Del fi RT fi CT Sur fi Del fi CT
Rectal cancer in pregnancycancer in pregnancy: A diagnostic and therapeutic challenge
Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
4 and compromise the fetus. A gentle flexible rectosigmoidoscopy may be preferred in a suspicious pregnant women having rectosigmoid cancer [4]. Ultrasound, a safe diagnostic modality in pregnancy, has limited accuracy in detecting colon and rectal masses. Likewise, magnetic resonance imaging (MRI) is relatively safe in pregnancy; however, the safety of contrast agents used with this imaging has not been approved for the fetus [8–10]. CT scan is the standard imaging study used for determining the locoregional and distant disease in colorectal cancer. It plays an important role for defining the surgical and radiation plans. However, X-ray imaging studies particularly the CT scan is contraindicated during pregnancy due their teratogenic and carcinogenic effects on the fetus. Therefore, there is a paucity of CT imaging findings in pregnancy in the literature [8,10]. In our patient, CT scan was performed after definite decision for terminating the pregnancy. Treatment of colorectal cancer in pregnancy is another challenging issue. As a rule, pregnant women should be offered optimal management as non-pregnant patients. Therefore, cancer treatment should be started as early as possible for the mother. Likewise, pregnancy termination should be performed as early as possible for saving the fetus. Accurate information should be provided by the oncologist for the patient. A treatment decision varies widely depending on the legal, ethical, personal, religious or emotional concepts [6,7,11]. Generally, in the first 20 weeks of pregnancy, treatment delay can lead to disease progression and compromise the mother’s life; therefore, pregnancy would be terminated and early cancer treatment should be started. In the second 20 weeks of pregnancy, surgery can be delayed for saving the fetus [3,7]. Most cases (64–86%) of colorectal cancer in pregnancy tend to involve the rectum and mainly (60%) present at stage III [12]. Therefore, a large portion of these patients need to receive neoadjuvant chemoradiation before rectal surgical resection [13,14]. However, pelvic radiation in pregnancy is associated with lethal damage to the fetus. Radiation exposure, particularly during organogenesis is contraindicated, because it is associated with embryonic or fetal death, malformation, and growth retardation [15]. In the literature, most rectal cancers in pregnancy occurred in the second or the third trimesters. These patients tend to present in stage III or IV and to have poor outcome [5,11,16–28] (Table 1). Most evidences indicate that neoadjuvant chemotherapy in pregnant women with metastatic rectal cancer spare the fetus; although it is not curative for mothers [5,16,19–21]. In this report, our patient had a locally advanced disease in the pelvis associated with resectable single liver metastasis; therefore, according to the patient’s desire termination of pregnancy followed by combined neoadjuvant chemotherapy and chemoradiation before surgical intervention was offered to the patient. Subsequent curative surgery and adjuvant systemic therapy was offered to her.
Conclusion Herein, we report a case of advanced rectal cancer presenting during pregnancy. This case suggests that colorectal cancer can mimic the signs and the symptoms of pregnancy and tends to present at an advanced stage in pregnant women.
M. Toosi et al. Conflict of interest The authors have no commercial or other associations that might pose a conflict of interest in connection with the manuscript. References [1] Safaee A, Moghimi-Dehkordi B, Fatem SR, Pourhoseingholi MA, Ghiasi S, Zali MR. Colorectal cancer in Iran: an epidemiological study. Asian Pac J Cancer Prev 2008;9:123–6. [2] Khodaverdi S, Kord Valeshabad A, Khodaverdi M. A case of colorectal cancer during pregnancy: a brief review of the literature. Case Rep Obstet Gynecol 2013;2013:626393. [3] Salani R, Billingsley CC, Crafton SM. Cancer and pregnancy: an overview for obstetricians and gynecologists. Am J Obstet Gynecol 2013, in press. [4] Yaghoobi M, Koren G, Nulman I. Challenges to diagnosing colorectal cancer during pregnancy. Can Fam Physician 2009; 55:881–5. [5] Dogan NU, Tastekin D, Kerimoglu OS, Pekin A, Celik C. Rectal cancer in pregnancy: a case report and review of the literature. J Gastrointest Cancer 2013;44:354–6. [6] Morice P, Uzan C, Uzan S. Cancer in pregnancy: a challenging conflict of interest. Lancet 2012;379:495–6. [7] Peccatori FA, Azim Jr HA, Orecchia R, Hoekstra HJ, Pavlidis N, Kesic V, et al. Cancer, pregnancy and fertility: ESMO clinical practice guidelines for diagnosis, treatment and followup. Ann Oncol 2013;24(Suppl. 6):vi160–70. [8] Baysinger CL. Imaging during pregnancy. Anesth Analg 2010; 110:863–7. [9] Chen MM, Coakley FV, Kaimal A, Laros Jr RK. Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation. Obstet Gynecol 2008;112: 333–40. [10] Hodnett PA, Maher MM. Imaging of gastrointestinal and hepatic diseases during pregnancy. Best Pract Res Clin Gastroenterol 2007;21:901–17. [11] Bukhari Y, Hogan NM, Pomeroy M, O’Leary M, Joyce MR. Surgical management of rectal cancer in pregnancy. Int J Colorectal Dis 2013;28:883–4. [12] Bernstein MA, Madoff RD, Caushaj PF. Colon and rectal cancer in pregnancy. Dis Colon Rectum 1993;36:172–8. [13] Omidvari S, Hamedi SH, Mohammadianpanah M, Razzaghi S, Mosalaei A, Ahmadloo N, et al. Comparison of abdominoperineal resection and low anterior resection in lower and middle rectal cancer. J Egypt Natl Canc Inst 2013;25:151–60. [14] Ghahramani L, Moaddabshoar L, Razzaghi S, Hamedi SH, Pourahmad S, Mohammadianpanah M. Prognostic value of total lymph node identified and ratio of lymph nodes in resected colorectal cancer. Ann Colorectal Res 2013;1:73–84. [15] Martin DD. Review of radiation therapy in the pregnant cancer patient. Clin Obstet Gynecol 2011;54:591–601. [16] Hojgaard HM, Rahr H. Rectal cancer in a pregnant woman, a case report. Ugeskr Laeger 2012;174:1827–8. [17] Araujo Junior E, Campanharo FF, Sun SY, Nardozza LM, Mattar R, Moron AF. Fulminant adenocarcinoma of the rectum with hepatic metastasis in a young pregnant woman: a case report. Case Rep Oncol 2012;5:208–11. [18] Ho MY, Cassano-Bailey A, Czaykowski P. Colorectal cancer in pregnancy: driven by pregnancy-associated growth factors? J Gastrointest Cancer 2012;43:s239–42. [19] Jeppesen JB, Osterlind K. Successful twin pregnancy outcome after in utero exposure to FOLFOX for metastatic colon cancer: a case report and review of the literature. Clin Colorectal Cancer 2011;10:348–52.
Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
Rectal cancer in pregnancycancer in pregnancy: A diagnostic and therapeutic challenge [20] Kanate AS, Auber ML, Higa GM. Priorities and uncertainties of administering chemotherapy in a pregnant woman with newly diagnosed colorectal cancer. J Oncol Pharm Pract 2009;15:5–8. [21] Gensheimer M, Jones CA, Graves CR, Merchant NB, Lockhart AC. Administration of oxaliplatin to a pregnant woman with rectal cancer. Cancer Chemother Pharmacol 2009;63:371–3. [22] Chourak M, Tahiri MH, Majbar A, Allala M, Najih M, Iraki H, et al. Colorectal cancer discovered during pregnancy. Gastroenterol Clin Biol 2009;33:1118–23. [23] Lolis ED, Likoudis P, Voiniadis P, Hassiakos D, Samanides L. Synchronous rectal and colon cancer caused by familial polyposis coli during pregnancy. J Obstet Gynaecol Res 2007; 33:199–202. [24] Harma M, Harma M, Uzunkoy A. Colorectal cancer presenting with uncommon soft tissue invasion during pregnancy. Acta Obstet Gynecol Scand 2005;84:491–3.
5
[25] Pigeau H, Dupre PF, Benouna J, Classe JM, Pioud R, Mahe MA, et al. Management of rectal cancer in pregnant women. Bull Cancer 2005;92:953–8. [26] Ruiz Molina JM, Ortiz-Mendoza CM, Mondragon Sanchez RJ, Aiello Crocifoglio V, Onate Ocana LF, Lopez Basave HN. Rectal cancer and pregnancy. Rev Gastroenterol Mex 2003; 68:293–5. [27] Ochshorn Y, Kupferminc MJ, Lessing JB, Pausner D, Geva E, Daniel Y. Rectal carcinoma during pregnancy: a reminder and updated treatment protocols. Eur J Obstet Gynecol Reprod Biol 2000;91:201–2. [28] Caforio L, Draisci G, Ciampelli M, Rossi B, Sollazzi L, Caruso A. Rectal cancer in pregnancy: a new management based on blended anesthesia and monitoring of fetal well being. Eur J Obstet Gynecol Reprod Biol 2000;88:71–4.
Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
Cairo University
Journal of the Egyptian National Cancer Institute www.nci.cu.adu.eg www.sciencedirect.com
Case Report
Rectal cancer in pregnancy: A diagnostic and therapeutic challenge Monireh Toosi a, Leila Moaddabshoar b, Seyed Ali Malek-Hosseini c, Mohammad Reza Sasani d, Maral Mokhtari e, Mohammad Mohammadianpanah
f,*
a
Department of Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran Student Research Committee, Resident of Radiation Oncology, Shiraz University of Medical Sciences, Shiraz, Iran c Organ Transplant Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran d Medical Imaging Research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran e Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran f Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran b
Received 15 February 2014; revised 13 March 2014; accepted 13 March 2014
KEYWORDS Rectal cancer; Pregnancy; Diagnosis; Treatment; Prognosis
Abstract Introduction: The occurrence of colorectal cancer during pregnancy is rare and is associated with diagnostic and therapeutic challenges. Herein, we report such a case of rectal cancer in pregnancy and review the literature. Case report: A 31-year-old multiparous, pregnant woman, in the 20th week of gestation, presented with rectal bleeding progressing to spasmodic abdominal pain and right flank vague pain. A flexible rectosigmoidoscopy showed a large ulcerative mass located in the rectosigmoid junction, 15 cm away from anal verge. Imaging studies and biopsy proved it to be rectal adenocarcinoma with single liver metastasis. The patient’s pregnancy was terminated and neoadjuvant therapy followed by curative surgery was performed. She is currently receiving adjuvant systemic therapy to eradicate potential micrometastatic disease. Conclusion: This case suggests that colorectal cancer can mimic the signs and the symptoms of pregnancy and tends to present at an advanced stage in pregnant women. ª 2014 Production and hosting by Elsevier B.V. on behalf of National Cancer Institute, Cairo University.
* Corresponding author. Address: Colorectal Research Center, Department of Radiation Oncology, Namazi Hospital, Shiraz 7193613511, Iran. Tel./fax: +98 711 6474320. E-mail addresses: [email protected], [email protected] (M. Mohammadianpanah). Peer review under responsibility of The National Cancer Institute, Cairo University.
Production and hosting by Elsevier
Introduction In developing countries, colorectal cancer is the fifth most common cancer in men and third in women [1]. However, the occurrence of colorectal cancer in women under 40 is uncommon and it is very rare during pregnancy [2]. The incidence of cancer in pregnancy ranges from 0.02% to 0.1%. Colorectal cancer is one of the eight most frequent malignant neoplasms in pregnancy [3]. This rare condition is associated with diagnostic and therapeutic challenges [4]. The signs and
1110-0362 ª 2014 Production and hosting by Elsevier B.V. on behalf of National Cancer Institute, Cairo University. http://dx.doi.org/10.1016/j.jnci.2014.03.003 Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
2
M. Toosi et al.
the symptoms of the pregnancy can mask colorectal cancer in a pregnant woman and lead to late diagnosis in advanced stages and poor treatment outcome [5]. In the present study, we report such a case of advanced rectal cancer presented during pregnancy. Case report A 31-year-old multiparous, pregnant woman (gravid 3, para 1), in the 20th week of gestation, presented with a 4-week history of rectal bleeding progressing to spasmodic abdominal pain and right flank vague pain. The patient’s past medical and family history was negative for malignancy. An abdominal and pelvis ultrasound showed an alive single 20th week fetus, wall thickening of rectosigmoid junction and a large single hypoechoic lesion in right posterior liver lobe. A flexible rectosigmoidoscopy showed a large ulcerative lesion in rectosigmoid junction 15 cm to 22 cm away from anal verge. Transrectal biopsy of the rectal lesion revealed well differentiated adenocarcinoma of the rectum (Fig. 1). An ultrasound-guided core needle biopsy of the liver lesion confirmed metastatic rectal adenocarcinoma (Fig. 2). The patient was discussed in a multidisciplinary medical council including specialities of gynecologic oncology, perinatologist, surgical oncology, medical oncology and radiation oncology. Therefore, termination of pregnancy and neoadjuvant chemotherapy and chemoradiation were suggested for the patient’s potentially resectable stage IV rectal cancer. According to the medical council suggestion, as well as the patient’s desire for therapeutic abortion, a computed tomography (CT) scan of the chest, abdomen and pelvis was performed for precise staging. In abdominal and pelvic CT scan, there was a single fetus (Fig. 3), and a locally advanced rectal tumor as significant wall thickening of rectosigmoid junction associated with enlarged perirectal and mesenteric lymph nodes. In addition, there was a large single mass in right posterior liver lobe (Fig. 4). Therefore, the patient’s pregnancy was terminated and 2 weeks later she was referred for neoadjuvant therapies. The patients received a cycle of neoadjuvant chemotherapy consisting of capecitabine 1000 mg/m2 twice daily for 14 of every
Figure 2 Trucut biopsy of the liver which shows involvement by well differentiated adenocarcinoma, H&E, ·100.
Figure 3 Contrast enhanced CT image of the abdomen and pelvis showing a single intrauterine fetus.
Figure 1 Rectosigmoid adenocarcinoma showing well differentiated glands containing atypical cells with high N/C ratio, hyperchromatism and stratification, H&E, ·400.
three weeks cycle, plus oxaliplatin 130 mg/m2 intravenously on day 1 (CAPEOX regimen); followed by concurrent neoadjuvant chemoradiation. Concurrent chemotherapy consists of oxaliplatin 130 mg/m2 intravenously on day 1, plus oral capecitabine 825 mg/m2 twice daily during the whole period of radiotherapy with weekend breaks. Two weeks after
Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
The last patient’s status
Alive with disease 10 months following delivery Alive without disease 12 months following delivery Dead 9 months following delivery Dead 2 weeks after diagnosis Alive without disease 5 years following initial diagnosis Dead 12 months following delivery Dead 4 months following delivery Alive with disease 3.5 years following delivery Alive without disease 23 months following initial diagnosis Alive without disease 8 months following delivery Dead 15 months following surgery Alive without disease 12 months following delivery Alive without disease 18 months following delivery Lost to follow up Dead soon due to brain metastases Alive without disease just following delivery Alive without disease just following delivery
Treatment sequence
3
Abbreviations: CT, Chemotherapy; Del, Delivery; Sur, Surgery; RT, Radiotherapy. a These authors reported 2 cases.
IV II IV IV II IV IV IV III III IV III III IV IV II III
Disease stage Gestational age (week)
19 18 36 21 21 13 23 20 38 27 37 32 32 30 39 38 26 38 35 32 17 29 26 40 25 30 29 30 31 28 25 34 27 32 2013 2013 2012 2012 2012 2011 2009 2009 2009 2007 2005 2005 2005 2003 2003 2000 2000 Dogan [5] Bukhari [11] Hojgaard [16] Araujo Junior [17] Ho [18] Jeppesen [19] Kanate [20] Gensheimer [21] Chourak [22] Lolis [23] Harma [24] Pigeau [25] Pigeau [25]a Ruiz Molina [26] Ruiz Molina [26]a Ochshorn [27] Caforio [28]
Patient’s age Year of publication Authors
There are many challenging issues regarding the diagnosis and management of colorectal cancer in pregnancy [6]. Colorectal cancer can be masked by the signs and the symptoms of the pregnancy. Spasmodic abdominal pain secondary to the partial large bowel obstruction may be considered as normal uterine cramps. As well, anorectal bleeding and pain may be misdiagnosed as a sequence of engorged hemorrhoid or anal fissure [2]. In our patient, occasional rectal bleeding and crampy abdominal pain was misdiagnosed as the signs and the symptoms of normal pregnancy by the patient for a few weeks. There are many limitations and contraindications for using diagnostic tools during pregnancy [7,8]. Colonoscopy and biopsy are golden standard tests for diagnosing colorectal cancer; however, this diagnostic test may complicate pregnancy
Table 1
Discussion
Fifteen reports of rectal cancer in pregnancy between 2000 and 2013.
Figure 4 Contrast enhanced CT image of the abdomen and pelvis showing significant tumoral wall thickening of rectosigmoid junction (white arrow) associated with liver mass (black arrow).
completion of chemoradiation, she received the 3rd cycle of neoadjuvant chemotherapy. Before surgical intervention, a new abdominal and pelvic CT scan showed marked regression of the rectal tumor; however, liver metastasis showed somewhat progression. The patient subsequently underwent staged curative surgical resection of the primary rectal tumor and liver metastasis. Adjuvant chemotherapy combined with targeted therapy using bevacizumab has been considered for the patients to eradicate potential micrometastatic disease.
CT fi Del fi CT Sur fi CT fi Del Sur fi Del fi CT No treatment Sur fi Del fi CT CT fi Del fi CT CT fi Del fi CT Sur fi CT fi Del fi CT Del fi Sur fi RT fi CT Del fi Sur fi RT fi CT Del fi Sur fi CT Del fi RT fi CT Del fi RT fi CT Sur fi Del fi CT Sur fi Del fi CT Del fi RT fi CT Sur fi Del fi CT
Rectal cancer in pregnancycancer in pregnancy: A diagnostic and therapeutic challenge
Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
4 and compromise the fetus. A gentle flexible rectosigmoidoscopy may be preferred in a suspicious pregnant women having rectosigmoid cancer [4]. Ultrasound, a safe diagnostic modality in pregnancy, has limited accuracy in detecting colon and rectal masses. Likewise, magnetic resonance imaging (MRI) is relatively safe in pregnancy; however, the safety of contrast agents used with this imaging has not been approved for the fetus [8–10]. CT scan is the standard imaging study used for determining the locoregional and distant disease in colorectal cancer. It plays an important role for defining the surgical and radiation plans. However, X-ray imaging studies particularly the CT scan is contraindicated during pregnancy due their teratogenic and carcinogenic effects on the fetus. Therefore, there is a paucity of CT imaging findings in pregnancy in the literature [8,10]. In our patient, CT scan was performed after definite decision for terminating the pregnancy. Treatment of colorectal cancer in pregnancy is another challenging issue. As a rule, pregnant women should be offered optimal management as non-pregnant patients. Therefore, cancer treatment should be started as early as possible for the mother. Likewise, pregnancy termination should be performed as early as possible for saving the fetus. Accurate information should be provided by the oncologist for the patient. A treatment decision varies widely depending on the legal, ethical, personal, religious or emotional concepts [6,7,11]. Generally, in the first 20 weeks of pregnancy, treatment delay can lead to disease progression and compromise the mother’s life; therefore, pregnancy would be terminated and early cancer treatment should be started. In the second 20 weeks of pregnancy, surgery can be delayed for saving the fetus [3,7]. Most cases (64–86%) of colorectal cancer in pregnancy tend to involve the rectum and mainly (60%) present at stage III [12]. Therefore, a large portion of these patients need to receive neoadjuvant chemoradiation before rectal surgical resection [13,14]. However, pelvic radiation in pregnancy is associated with lethal damage to the fetus. Radiation exposure, particularly during organogenesis is contraindicated, because it is associated with embryonic or fetal death, malformation, and growth retardation [15]. In the literature, most rectal cancers in pregnancy occurred in the second or the third trimesters. These patients tend to present in stage III or IV and to have poor outcome [5,11,16–28] (Table 1). Most evidences indicate that neoadjuvant chemotherapy in pregnant women with metastatic rectal cancer spare the fetus; although it is not curative for mothers [5,16,19–21]. In this report, our patient had a locally advanced disease in the pelvis associated with resectable single liver metastasis; therefore, according to the patient’s desire termination of pregnancy followed by combined neoadjuvant chemotherapy and chemoradiation before surgical intervention was offered to the patient. Subsequent curative surgery and adjuvant systemic therapy was offered to her.
Conclusion Herein, we report a case of advanced rectal cancer presenting during pregnancy. This case suggests that colorectal cancer can mimic the signs and the symptoms of pregnancy and tends to present at an advanced stage in pregnant women.
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Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003
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Please cite this article in press as: Toosi M et al. Rectal cancer in pregnancy: A diagnostic and therapeutic challenge, J Egyptian Nat Cancer Inst (2014), http://dx.doi.org/10.1016/j.jnci.2014.03.003