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Sigmoid colon cancer during pregnancy
European Journal of Obstetrics & Gynecology and Reproductive Biology 104 (2002) 70–72
Case report
Sigmoid colon cancer during pregnancy Nicolaos Vitoratos*, Emanuel Salamalekis, Evangelos Makrakis, George Creatsas Second Department of Obstetrics and Gynaecology, Aretaieion Hospital, University of Athens, 76 Vas. Sophias Avenue, Athens 115 28, Greece Received 5 February 2001; received in revised form 30 October 2001; accepted 22 January 2002
Abstract Colorectal carcinoma during pregnancy is a rare event. We report a 23-year-old primigravida with advanced stage adenocarcinoma of the sigmoid colon diagnosed at 34 weeks of gestation. A healthy female infant was delivered by cesarean section. The treatment of choice was chemotherapy. The patient died 3 months after delivery. # 2002 Published by Elsevier Science Ireland Ltd. Keywords: Pregnancy; Colon carcinoma; Colonoscopy
1. Introduction Colorectal carcinoma during pregnancy is a rare event occurring in 0.002% of all pregnancies [1]. Most patients present in late pregnancy and more than 80% of them have rectal tumours. Staging and prognosis are not different from those in non-pregnant women with colorectal carcinoma [2]. Because of the similarity between the early symptoms of colon cancer and the gastrointestinal complains of pregnancy, diagnosis is usually delayed and the patient present with advanced tumour having a poor prognosis. We report a case of colorectal carcinoma presenting in a young pregnant woman.
2. Case report A 23-year-old primigravida was admitted at 34 weeks of gestation to our clinic, with a month’s history of per rectum bleeding and weight loss. No history of familial polyposis or colorectal carcinoma could be obtained. Physical examination on admission was normal apart from hemorrhoids of second degree. Fetal growth was consistent with gestational age and blood as well as urine analyses were normal. Liver as well as thyroid function tests were also normal (total bilirubin: 0.34 mg/dl; AST-SGOT: 17.4 U/l; ALT-SGPT: 18.3 U/l; alkaline phosphatase: 63.2 U/l; gGT: 12.3 U/l; TSH: 1.01 mIU/ml; FTI: 9.2 mg%). *
Corresponding author. Fax: þ30-1-6826447. E-mail address: [email protected] (N. Vitoratos).
Per rectum examination and proctoscopy revealed hemorrhoids of second degree. However, the mucus of the rectum, otherwise normal, was coated by stools mixed up with blood. This finding was the incitement for further investigation. Thus, colonoscopy was performed, which revealed, in 25 cm depth, an ulcerated mass causing narrowing of the lumen of the sigmoid colon (Fig. 1). Six biopsies were taken and the histopathologic examination showed an undifferentiated adenocarcinoma. Ultrasonography of the upper abdomen showed multiple hypogenic areas of the liver, characteristic of secondary metastatic disease (Fig. 2). The tumour markers such as CA-125, CA 15-3 and CEA were evaluated. Serum levels of CA-125 and CA 15-3 were within the normal ranges (8.9 ml and 10 U/ml, respectively). Higher than normal (0–3 ng/ml) serum levels of CEA (11.4 ng/ml) were found. A cesarean section was performed 2 weeks later and a 2650 g healthy female infant was born. During the operation an exploration of the abdomen was performed and an inoperable disease of sigmoid colon which was spread all over the abdomen was found. She was discharged 6 days following the operation and started therapy with 5-Fu and leucovorin. The patient died 3 months after delivery.
3. Discussion The first case of large intestine carcinoma during pregnancy was reported by Evers in 1928. The majority of colorectal tumours diagnosed during pregnancy are rectal
0301-2115/02/$ – see front matter # 2002 Published by Elsevier Science Ireland Ltd. PII: S 0 3 0 1 - 2 1 1 5 ( 0 2 ) 0 0 0 5 2 - 0
N. Vitoratos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 104 (2002) 70–72
Fig. 1. The ulcerated mass in the lumen of sigmoid colon.
carcinomas [2] and only 33 cases of tumours arising above the peritoneal reflection have been described in the literature. The initial symptoms of colon carcinoma are vomiting, abdominal pain and constipation, which are usually attributed to the pregnancy. Thus, metastatic spread, bowel obstruction and subsequent perforation are more frequent during pregnancy. In our case, the main symptoms on admission were rectal bleeding and weight loss, while the disease was already spread to the liver. Even though colorectal carcinoma is mainly seen in the middle-aged and elderly people, 2–6% of large intestine tumours is diagnosed before the age of 40 years. However,
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when a colon carcinoma develops in a young woman during pregnancy, it is considered as a lethal disease due to its rapid progression. There is no doubt that the delay in the diagnosis as well as the young age of the patient are the main factors responsible for the poor prognosis, but the occurrence of a colon carcinoma during pregnancy arise questions about any possible link to rapid cell growth and proliferation associated with gestation. The balance among tumour suppression, apoptosis and abnormal cellular proliferation can be altered during pregnancy. On the other hand, the gene p53 was found to be mutated in human colorectal tumours. Several studies demonstrated that p53 suppresses cancer cell growth in vitro and suggested p53 as a regulator of cell growth and a tumour suppressor gene [3,4]. Thus, a hypothesis could be that the development of colon carcinoma during pregnancy might be attributed to alterations of the p53 tumour suppressor gene or its products in addition to the maternal tolerant state [5]. The rate of infant survival in pregnancies complicated with colorectal carcinomas is reported to be 78.1% [1]. The outcome for the fetus seems to be good mainly because metastasis of colorectal tumours to the products of conception has not been described [6]. Indeed, in our case a healthy female infant was born, but the mother died soon after the delivery. Thus, it is important not to underestimate the patient’s symptoms because the early diagnosis is essential for better prognosis. Chemotherapy has a limited role in the treatment of pregnant women with colorectal carcinoma especially in those with advanced disease [2]. Our patient died 3 months after the initiation of chemotherapy. We hope that the development of new adjuvant therapies in the future will improve the prognosis of patients with metastatic colorectal neoplasia.
Fig. 2. Multiple hypogenic areas of the liver.
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N. Vitoratos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 104 (2002) 70–72
4. Condensation Report of an advanced stage adenocarcinoma of the sigmoid colon diagnosed at 34 weeks of gestation. References [1] Shushan A, Stemmer SM, Renbinoff BE, Fid A, Weinstein D. Carcinoma of the colon during pregnancy. Obstet Gynecol Surv 1992;47:222. [2] Walsh C, Fazio VW. Cancer of the colon, rectum, and anus during pregnancy. The surgeon’s perspective. Gastroenterol Clin North Am 1998;27:257–67.
[3] Rojansky N, Shushan A, Livni N, Jurim O, Sulam M, Galun E. Case report: pregnancy associated with colon carcinoma overexpressing p53. Gynecol Oncol 1997;64:516–20. [4] Levine AJ. The p53 tumour suppressor gene. N Engl N Med 1992;326:1350–2. [5] Kitox T, Nishimura S, Fukuda S, Fukuda S, Hirabuki S, Kaganoi J, et al. The incidence of colorectal cancer during pregnancy in Japan: report of two cases and review of Japanese cases. Am J Perinatal 1998;15:165–71. [6] Balloni L, Pugliese P, Ferrari S, Danova M, Porta C. Colon cancer in pregnancy: report of a case and review of the literature. Tumour 2000;86:95–7.
Case report
Sigmoid colon cancer during pregnancy Nicolaos Vitoratos*, Emanuel Salamalekis, Evangelos Makrakis, George Creatsas Second Department of Obstetrics and Gynaecology, Aretaieion Hospital, University of Athens, 76 Vas. Sophias Avenue, Athens 115 28, Greece Received 5 February 2001; received in revised form 30 October 2001; accepted 22 January 2002
Abstract Colorectal carcinoma during pregnancy is a rare event. We report a 23-year-old primigravida with advanced stage adenocarcinoma of the sigmoid colon diagnosed at 34 weeks of gestation. A healthy female infant was delivered by cesarean section. The treatment of choice was chemotherapy. The patient died 3 months after delivery. # 2002 Published by Elsevier Science Ireland Ltd. Keywords: Pregnancy; Colon carcinoma; Colonoscopy
1. Introduction Colorectal carcinoma during pregnancy is a rare event occurring in 0.002% of all pregnancies [1]. Most patients present in late pregnancy and more than 80% of them have rectal tumours. Staging and prognosis are not different from those in non-pregnant women with colorectal carcinoma [2]. Because of the similarity between the early symptoms of colon cancer and the gastrointestinal complains of pregnancy, diagnosis is usually delayed and the patient present with advanced tumour having a poor prognosis. We report a case of colorectal carcinoma presenting in a young pregnant woman.
2. Case report A 23-year-old primigravida was admitted at 34 weeks of gestation to our clinic, with a month’s history of per rectum bleeding and weight loss. No history of familial polyposis or colorectal carcinoma could be obtained. Physical examination on admission was normal apart from hemorrhoids of second degree. Fetal growth was consistent with gestational age and blood as well as urine analyses were normal. Liver as well as thyroid function tests were also normal (total bilirubin: 0.34 mg/dl; AST-SGOT: 17.4 U/l; ALT-SGPT: 18.3 U/l; alkaline phosphatase: 63.2 U/l; gGT: 12.3 U/l; TSH: 1.01 mIU/ml; FTI: 9.2 mg%). *
Corresponding author. Fax: þ30-1-6826447. E-mail address: [email protected] (N. Vitoratos).
Per rectum examination and proctoscopy revealed hemorrhoids of second degree. However, the mucus of the rectum, otherwise normal, was coated by stools mixed up with blood. This finding was the incitement for further investigation. Thus, colonoscopy was performed, which revealed, in 25 cm depth, an ulcerated mass causing narrowing of the lumen of the sigmoid colon (Fig. 1). Six biopsies were taken and the histopathologic examination showed an undifferentiated adenocarcinoma. Ultrasonography of the upper abdomen showed multiple hypogenic areas of the liver, characteristic of secondary metastatic disease (Fig. 2). The tumour markers such as CA-125, CA 15-3 and CEA were evaluated. Serum levels of CA-125 and CA 15-3 were within the normal ranges (8.9 ml and 10 U/ml, respectively). Higher than normal (0–3 ng/ml) serum levels of CEA (11.4 ng/ml) were found. A cesarean section was performed 2 weeks later and a 2650 g healthy female infant was born. During the operation an exploration of the abdomen was performed and an inoperable disease of sigmoid colon which was spread all over the abdomen was found. She was discharged 6 days following the operation and started therapy with 5-Fu and leucovorin. The patient died 3 months after delivery.
3. Discussion The first case of large intestine carcinoma during pregnancy was reported by Evers in 1928. The majority of colorectal tumours diagnosed during pregnancy are rectal
0301-2115/02/$ – see front matter # 2002 Published by Elsevier Science Ireland Ltd. PII: S 0 3 0 1 - 2 1 1 5 ( 0 2 ) 0 0 0 5 2 - 0
N. Vitoratos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 104 (2002) 70–72
Fig. 1. The ulcerated mass in the lumen of sigmoid colon.
carcinomas [2] and only 33 cases of tumours arising above the peritoneal reflection have been described in the literature. The initial symptoms of colon carcinoma are vomiting, abdominal pain and constipation, which are usually attributed to the pregnancy. Thus, metastatic spread, bowel obstruction and subsequent perforation are more frequent during pregnancy. In our case, the main symptoms on admission were rectal bleeding and weight loss, while the disease was already spread to the liver. Even though colorectal carcinoma is mainly seen in the middle-aged and elderly people, 2–6% of large intestine tumours is diagnosed before the age of 40 years. However,
71
when a colon carcinoma develops in a young woman during pregnancy, it is considered as a lethal disease due to its rapid progression. There is no doubt that the delay in the diagnosis as well as the young age of the patient are the main factors responsible for the poor prognosis, but the occurrence of a colon carcinoma during pregnancy arise questions about any possible link to rapid cell growth and proliferation associated with gestation. The balance among tumour suppression, apoptosis and abnormal cellular proliferation can be altered during pregnancy. On the other hand, the gene p53 was found to be mutated in human colorectal tumours. Several studies demonstrated that p53 suppresses cancer cell growth in vitro and suggested p53 as a regulator of cell growth and a tumour suppressor gene [3,4]. Thus, a hypothesis could be that the development of colon carcinoma during pregnancy might be attributed to alterations of the p53 tumour suppressor gene or its products in addition to the maternal tolerant state [5]. The rate of infant survival in pregnancies complicated with colorectal carcinomas is reported to be 78.1% [1]. The outcome for the fetus seems to be good mainly because metastasis of colorectal tumours to the products of conception has not been described [6]. Indeed, in our case a healthy female infant was born, but the mother died soon after the delivery. Thus, it is important not to underestimate the patient’s symptoms because the early diagnosis is essential for better prognosis. Chemotherapy has a limited role in the treatment of pregnant women with colorectal carcinoma especially in those with advanced disease [2]. Our patient died 3 months after the initiation of chemotherapy. We hope that the development of new adjuvant therapies in the future will improve the prognosis of patients with metastatic colorectal neoplasia.
Fig. 2. Multiple hypogenic areas of the liver.
72
N. Vitoratos et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 104 (2002) 70–72
4. Condensation Report of an advanced stage adenocarcinoma of the sigmoid colon diagnosed at 34 weeks of gestation. References [1] Shushan A, Stemmer SM, Renbinoff BE, Fid A, Weinstein D. Carcinoma of the colon during pregnancy. Obstet Gynecol Surv 1992;47:222. [2] Walsh C, Fazio VW. Cancer of the colon, rectum, and anus during pregnancy. The surgeon’s perspective. Gastroenterol Clin North Am 1998;27:257–67.
[3] Rojansky N, Shushan A, Livni N, Jurim O, Sulam M, Galun E. Case report: pregnancy associated with colon carcinoma overexpressing p53. Gynecol Oncol 1997;64:516–20. [4] Levine AJ. The p53 tumour suppressor gene. N Engl N Med 1992;326:1350–2. [5] Kitox T, Nishimura S, Fukuda S, Fukuda S, Hirabuki S, Kaganoi J, et al. The incidence of colorectal cancer during pregnancy in Japan: report of two cases and review of Japanese cases. Am J Perinatal 1998;15:165–71. [6] Balloni L, Pugliese P, Ferrari S, Danova M, Porta C. Colon cancer in pregnancy: report of a case and review of the literature. Tumour 2000;86:95–7.