Colorectal carcinoma in pregnancy

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.

Challenges in management of gastrointestinal cancers in pregnancies: A report of three cases

Gastrointestinal cancer occurs in approximately 1 in 13,000 pregnancies, making up 4% of malignancies detected in pregnancy. It is a complex and challenging condition to diagnose and manage and is often only detected in its more advanced stages. This is partly due to symptoms of gastrointestinal cancer being incorrectly attributed to physiological symptoms of pregnancy, as well as concerns about the safety of diagnostic investigations in pregnancy, both of which may delay diagnosis and lead to disease progression. Challenges in management also arise from under-treatment in pregnancy due to concerns about the impact of surgery or chemotherapy on the pregnancy. We present here three cases of gastrointestinal cancer diagnosed in pregnancy in our centre and discuss the challenges and pitfalls one may encounter in the diagnosis and management of gastrointestinal malignancies in pregnancy.

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

BACKGROUND

Colorectal cancer in pregnancy is rare, with an incidence of 0.8 per 100,000 pregnancies. Advanced disease (stage III or IV) is diagnosed more frequently in pregnant patients. We aimed to review all cases of colorectal cancer in pregnancy from the International Network on Cancer, Infertility and Pregnancy database in order to learn more about this rare disease and improve its management.

METHODS

Data on the demographic features, symptoms, histopathology, diagnostic and therapeutic interventions and outcomes (obstetric, neonatal and maternal) were analysed.

RESULTS

Twenty-seven colon and 14 rectal cancer cases were identified. Advanced disease was present in 30 patients (73.2%). During pregnancy, 21 patients (51.2%) received surgery and 12 patients (29.3%) received chemotherapy. Thirty-three patients (80.5%) delivered live babies: 21 by caesarean section and 12 vaginally. Prematurity rate was high (78.8%). Eight babies were small for gestational age (27.6%). Three patients (10.7%) developed recurrence of disease. Overall 2-year survival was 64.4%.

CONCLUSION

Despite a more frequent presentation with advanced disease, colorectal cancer has a similar prognosis in pregnancy when compared with the general population. Diagnostic interventions and treatment should not be delayed due to the pregnancy but a balance between maternal and foetal wellbeing must always be kept in mind.

Adenocarcinoma of the ascending colon in a 31-year-old pregnant woman: A case report

RATIONALE

Colorectal cancer (CRC) is the 2nd most common type of cancer in females and the 3rd in males, worldwide. It occurs rarely during pregnancy and is often associated with poor prognosis, due to the unspecific manifestations until advanced stage. Majority of CRC are localized in the rectum (63%) and the sigmoid colon (20%) during pregnancy.

PATIENT CONCERNS

In thisstudy, we report the case of a pregnant woman who was diagnosed with adenocarcinoma of the ascending colon at her 33rd gestational week. She was referred to our department from local hospital with low fever and right-sided flank pain, which had lasted for nearly half a year and severely aggravated for 5 days. Previous prenatal examinations contributed the pain to kidney stones or uterine contractions.

DIAGNOSES

After a caesarean section and tumor resection of a mass at the hepatic flexure of colon, tumor histology of frozen section confirmed the diagnosis of ulcerative adenocarcinoma of the ascending colon with a diameter of 10 cm. Final pathologic evaluation showed a grade 1 adenocarcinoma with negative lymph nodes (16/0), R0 resection, pT4b pN0 M0 and Dukes B stage.

INTERVENTIONS

A healthy female infant was delivered by caesarean section, right after which a right hemicolectomy and ileostomy was performed. Pathology examination proved an early stage adenocarcinoma with no lymphatic metastasis. Patient received chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) after recovery smoothly and got discharged 1 month after surgery.

OUTCOMES

Patient showed no relapse or progression during the follow-up time of 2 years after operation and chemotherapy.

LESSONS

Rare occurrence of CRC during pregnancy and limited experience concerning its diagnosis and treatment bring obstacle to both patients and physicians. Symptoms as constipation and abdominal pain must be inspected carefully. With a perfect coordination between different disciplines, CRC with pregnancy can be ideally treated with better prognosis.

Cancer in Pregnancy

This article reviews some of the more common types of cancer that may be encountered during pregnancy. It reviews the unique challenges with the diagnosis and treatment of breast, cervical, hematologic, and colon cancers in pregnant patients.

Colon Cancer in Pregnancy: Report of a Case and Review of the Literature

Most colon cancer cases occur in patients over 50 years of age, although about 3% of colorectal cancer patients are younger than 40. During pregnancy the incidence of this neoplasm is estimated to be 0.002%. To date only 32 cases of colonic cancer arising above the peritoneal reflection during pregnancy have been described in the literature. We report another such case, stressing the need for constant alertness on the part of physicians in the presence of abdominal pain and/or distension, a palpable abdominal mass, rectal bleeding and/or weight loss during pregnancy. In fact, the reportedly poorer prognosis of this cancer in pregnant patients is mainly due to the fact that the initial symptoms of the malignancy are usually attributed by the patient, but also by physicians, to normal pregnancy.

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.

Chemotherapeutic treatment of colorectal cancer in pregnancy: case report

INTRODUCTION

Colon cancer in pregnancy is uncommon. Only a small number of case reports have been published in the literature on the use of chemotherapeutic drugs during pregnancy. Reports of such cases assist clinicians in further investigating the use of chemotherapy in pregnancy.

CASE PRESENTATION

FOLFOX-6 was administered to a pregnant, 33-year-old Saudi woman with metastatic colon cancer from 22 to 30 weeks of gestation. Her cancer was diagnosed during her pregnancy. She tolerated the chemotherapy well and delivered a full-term baby girl with no obvious harm, and normal development was documented at her 2-year follow-up examination.

CONCLUSION

Colon cancer during pregnancy is not easily detected and is difficult to manage. A detailed history and high clinical suspicion are needed in patients who present with symptoms and signs suggestive of malignancy. A multidisciplinary approach with patient involvement is needed to decrease morbidity and mortality caused by both treatment and the cancer in the mother and to limit side effects for the fetus. Further data and long-term follow-up are needed to better understand the potential long-term side effects of chemotherapeutic drugs on offspring.

Rectal Cancer Diagnosed after Cesarean Section in Which High Microsatellite Instability Indicated the Presence of Lynch Syndrome

We report a case of rectal cancer with microsatellite instability (MSI) that probably resulted from Lynch syndrome and that was diagnosed after Cesarean section. The patient was a 28-year-old woman (gravid 1, para 1) without a significant medical history. At 35 gestational weeks, vaginal ultrasonography revealed a 5 cm tumor behind the uterine cervix, which was diagnosed as a uterine myoma. The tumor gradually increased in size and blocked the birth canal, resulting in the patient undergoing an emergency Cesarean section. Postoperatively, the tumor was diagnosed as rectal cancer with MSI. After concurrent chemoradiation therapy, a lower anterior resection was performed. The patient's family history revealed she met the criteria of the revised Bethesda guidelines for testing the colorectal tumor for MSI. Testing revealed that the tumor did indeed show high MSI and, combined with the family history, suggested this could be a case of Lynch syndrome. Our findings emphasize the importance of considering the possibility of Lynch syndrome in pregnant women with colorectal cancer, particularly those with a family history of this condition. We suggest that the presence of Lynch syndrome should also be considered for any young woman with endometrial, ovarian, or colorectal cancer.

Obstructing adenocarcinoma of the descending colon in a 31-year-old pregnant woman

INTRODUCTION

Colon cancer in pregnant women is rare and tends to produce unspecific symptoms until advanced stage. Therefore common manifestations during pregnancy must be properly evaluated to avoid delayed diagnosis.

PRESENTATION OF CASE

A 31-year-old pregnant woman presented with nausea, vomiting and obstipation. An obtained magnetic resonance imaging (MRI) showed distended colon and the consecutive colonoscopy with biopsies confirmed the diagnosis of stenosing carcinoma of the descending colon. Left sided hemicolectomy was performed 10 days after initial presentation. Tumor histology confirmed the diagnosis of adenocarcinoma of the descendo-sigmoidal junction. Adjuvant chemotherapy with 5-fluorouracil was started in the 29th gestational week. The patient had an uneventful delivery of a healthy baby in her 39th gestational week.

DISCUSSION

Colorectal carcinoma during pregnancy is a rare event and its diagnosis is often delayed because symptoms are unspecific until the disease is advanced. Although constipation in pregnancy is a common symptom differential diagnosis of a mechanical stenosis should always be contemplated, especially when conservative treatment of constipation fails. MRI is the imaging tool of choice as abdominal computed tomography (CT) is contraindicated in pregnancy. Endoscopic confirmation should be obtained to gain pathological diagnosis of colorectal carcinoma. Surgery is the gold standard of treatment. In relation to the stage of the disease chemotherapy is of great importance.

CONCLUSION

Obstructing colorectal cancer can be a rare reason for the common problem of constipation in pregnancy. Beside clinical examination, MRI scan and colonoscopy will reveal the tumor in most cases and should be followed by surgical treatment and chemotherapy according to the stage of disease.

A Case of Colorectal Cancer during Pregnancy: A Brief Review of the Literature

The incidence of colorectal cancer (CRC) during pregnancy is so rare. Herein we present a case of colorectal cancer that was missed by pregnancy all over the pregnancy period. The patient was a 37-year-old woman (gravid 4, para 2) referred with the complaints of vaginal discharge and suspicious rupture of membrane (ROM). The patient was pale and the initial physical examination revealed dilation of two fingers, effacement about 30%. She underwent emergent cesarean section which showed adhesions surrounding the uterus, the bladder, and the abdominal wall. Forty days postoperatively, the patient presented with abdominal pain in the left upper quadrant (LUQ). Imaging confirmed a mass in LUQ. Partial colectomy of transverse colon (20 cm) was performed. Postoperative histopathologic study revealed a 7 ∗ 6 ∗ 5 cm mass in transverse colon compatible to stage IIa of the Duck class (T3, N0, Mx). Adjuvant chemotherapy was applied and the patient showed improvements during 7 months followup after surgery. Colorectal cancer in pregnancy is associated with diagnostic and therapeutic challenges which mostly lead to late diagnosis in advanced stages and poor prognosis. A targeted program to improve the general population knowledge and the establishment of a national consultant and screening program particularly for women with a planned pregnancy in the high risk group might be beneficial.

Fulminant adenocarcinoma of the rectum with hepatic metastasis in a young pregnant woman: a case report

Cancer is the second leading cause of death during the reproductive years, but the incidence during pregnancy is low. The incidence of cancer of the rectum during pregnancy is very rare (1:50,000 to 1:100,000 pregnancies). Usually, the symptoms of this type of cancer are nonspecific and sometimes they are confused with normal changes of pregnancy. The diagnosis of rectal cancer is usually made in the late stage of pregnancy. The treatment of this cancer involves surgery, chemotherapy and radiotherapy, but each type of treatment involves risks to the fetus and the pregnant woman. We present a case of a young primiparous woman who had a quick and bad evolution of an adenocarcinoma of the rectum diagnosed during pregnancy. This patient had extensive involvement of the liver with metastasis and she died two weeks after diagnosis. In this case, we present the clinical, radiological and pathology findings of this disease.

A Case of Hyperemesis Gravidarum due to Gastric Cancer Masquerading as Preeclampsia

Nausea and vomiting are symptoms frequently seen in normal pregnancy. We report a patient with gastric carcinoma who presented with severe hyperemesis gravidarum that led to extreme volume depletion, hypertension, proteinuria, and acute renal failure. A 35-year-old woman (para 2-1-0-1) with a prenatal course significant for persistent nausea, vomiting, and poor weight gain presented at 36 weeks' gestation with elevated blood pressure (157/114 mm Hg), proteinuria (4+), hypochloremic metabolic alkalosis, and severe intravascular volume contraction. A presumptive diagnosis of severe preeclampsia was made, the patient was given intravenous MgSO4, and cesarean delivery was accomplished uneventfully. When significant emesis persisted in the postoperative period, esophagogastroduodenoscopy revealed an antral/prepyloric mass with a biopsy-proven poorly differentiated adenocarcinoma. To our knowledge, this is the first report of a case of hyperemesis gravidarum with gastric cancer masquerading as preeclampsia.

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

Surgical gastrointestinal disorders during pregnancy

All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the experienced surgeon must come into play in order to make the correct therapeutic decisions when evaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain the same as those governing the treatment of the non-pregnant patient, some important differences are present and can pose problems. As a general rule the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother.

[Colorectal cancer discovered during pregnancy]

Colorectal carcinoma during pregnancy is very rare. Prognosis is severe because of the advanced stage due to delay in diagnosis and the aggressiveness of this widespread metastatic disease. We report the case of colon metaststic adenocarcinoma during a twin pregnancy with a good outcome. In the light of epidemiology, pathogeny and immunology, the diagnostic challenge for clinicians is distinguishing pregnancy symptoms from the warning signs of colorectal cancer and, we describe recommended medical and surgical management.

Flexible sigmoidoscopy and colonoscopy during pregnancy

More than 6000 pregnant women each year have an indication that warrants a flexible sigmoidoscopy or colonoscopy. In addition to the potential complications inherent in the risk of sedation and the procedures themselves, the endoscopist who performs these procedures in pregnant women must be aware of the potential to do harm to the fetus. This article reviews the existing literature as it pertains to flexible sigmoidoscopies and colonoscopies performed during pregnancy, including indications and diagnostic usefulness, safety, use of medications, and therapeutic interventions.

Gastrointestinal, Pancreatic, and Hepatic Cancer During Pregnancy

Pregnancy affects the clinical presentation, evaluation, treatment, and prognosis of patients with gastrointestinal cancer. Pregnant patients may present with advanced gastrointestinal cancer as a result of delayed diagnosis, in part because of difficulty differentiating signs and symptoms of cancer from signs and symptoms of normal pregnancy. The approach to cancer surgery and chemotherapy must be modified in pregnant patients to minimize fetal and maternal risks. Because of these factors, women who develop gastrointestinal cancers during pregnancy seem to have a poor prognosis. This article focuses on cancers of the colon, stomach, pancreas, and liver that occur during pregnancy.

Management of Colorectal Cancer in Pregnancy: A Multimodality Approach

Colorectal cancer (CRC) is one of the 3 most common types of cancer in women, but CRC during pregnancy is rare, with a reported incidence of approximately 0.002%. Synchronous colon cancer during pregnancy presents a diagnostic and therapeutic challenge for clinicians because there are no generally accepted guidelines regarding diagnosis or treatment. The diagnosis is challenging because the presenting signs/symptoms of CRC are often attributed to the usual complications of pregnancy, which could delay the diagnosis and allow the cancer to progress to an advanced stage. Carcinogenesis of colon cancer in pregnancy is not clear, but a few studies suggest that the increased levels of estrogen and progesterone related to pregnancy stimulate the growth of CRC with their receptors. The aim of treatment is to start therapy for the mother as early as possible and to simultaneously deliver the baby at the earliest time allowable. The management mandates a multidisciplinary approach involving experts in obstetrics, neonatology, gastrointestinal surgery, and medical oncology. The medical community should be able to diagnose colon cancer earlier in pregnancy in order to improve prognosis. The primary care physician or obstetrician should refer the pregnant patient with significant gastrointestinal symptoms to the gastroenterologist for evaluation. Likewise, the gastroenterologist should be prepared to perform sigmoidoscopy (preferably without endoscopic medications) for significant lower gastrointestinal symptoms such as persistent rectal bleeding. Herein, the author reviews the literature concerning the diagnosis and treatment of CRC in pregnancy and discusses the role of newer agents approved for the treatment of CRC.

Colorectal cancer associated with pregnancy in Kaduna

The incidence of colorectal cancer associated with pregnancy is low. Only 2-6% of all females suffering from colorectal cancer are within the child bearing age (i.e. under 40 years). This paper describes the experience at the Ahmadu Belle University Teaching Hospital, Kaduna, Nigeria, from 1 January 1975 to 31 December 1997. Twenty-five cases of colorectal cancer associated with pregnancy were seen and treated; 15 cases in which colorectal cancer occurred de novo in pregnant patients; and 10 cases in which pregnancy(ies) occurred in patients with a previous diagnosis of colorectal cancer. Treatment of the cancer, future pregnancies and their management, and the question of possible prophylactic oophorectomy in selected patients are discussed.

Colorectal carcinoma in young females

BACKGROUND

We sought to study the clinicopathologic characteristics of colorectal cancer in young female patients. We also wanted to determine the association of colorectal cancer with anemia in these female patients and, finally, to determine the effect of gender on prognosis in young patients with colorectal cancer.

METHODS

We performed a retrospective analysis of all young patients diagnosed with colorectal cancer between 1982 and 1999 in two teaching hospitals in New York City.

RESULTS

A total of 3,546 cases of colorectal cancer were diagnosed. Sixty-one (1.63%) of these patients were young patients and 32 (0.85%) were female. Young refers to all patients in the study who were younger than 40 years of age. The clinical presentation and mean age at presentation were very similar in both male and female patients. At presentation, 87.5% of female patients had anemia compared with only 69% of male patients. Males had a statistically significant higher mean hemoglobin level compared with females (12.87 versus 10.29 g) at P = 0.0001. Seventy-nine percent of female patients compared with 86% of male patients presented with left-sided tumors. Fifty-five percent of males presented with late stage disease compared with 68% of females (P = 0.27). Female sex seemed to adversely affect the prognosis, although this did not reach statistical significance (P = 0.08). Stage of disease was associated with worse prognosis and this was independent of sex. Age and hemoglobin were not independent predictors of mortality.

CONCLUSION

Colorectal cancer does occur in females of childbearing age who might have a tendency to present with late stage disease as evidence from this study. Young female patients with anemia should be questioned about gastrointestinal symptoms, and colorectal cancer should definitely be in the differential diagnoses. This might conceivably allow for earlier diagnosis and potential for cure in this patient group.

Colon cancer during pregnancy

The medical community should become mobilized to diagnose colon cancer earlier in pregnancy to improve prognosis. The primary care physician or obstetrician should refer the pregnant patient with significant gastrointestinal complaints to the gastroenterologist for evaluation. Likewise, the gastroenterologist should be prepared to perform sigmoidoscopy, preferably without endoscopic medications, for significant lower gastrointestinal symptoms such as persistent rectal bleeding. Sigmoidoscopy is particularly sensitive in identifying colon cancer in pregnant patients because their cancers are usually distal and within reach of the sigmoidoscope.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.

Rectal carcinoma during pregnancy: a reminder and updated treatment protocols

Rectal carcinoma is rare during pregnancy. Prognosis is usually unfavorable due to late diagnosis, and management, especially regarding the mode of delivery, is controversial. Current treatment of rectal carcinoma includes neoadjuvant chemoradiotherapy, which may influence obstetrical management. We present a case report and discuss obstetrical management in view of updated knowledge and therapeutic approaches.

Hyperemesis in late pregnancy--should we think of cancer? A case report

Gastric cancer is unusual during pregnancy. The diagnosis may be delayed because specific symptoms are similar to typical pregnancy associated complaints. Our therapeutic management with palliative chemotherapy and later gastrectomy differs from other known cases, where surgical resection has been the treatment of choice. Surgery appears to have no influence on the prognosis of gastric cancer patients with hepatic metastases.

Colorectal cancer complicating pregnancy

Colorectal carcinoma complicating pregnancy is rare but associated with a high maternal mortality rate. Stage for stage the survival data are the same for pregnant patients and nonpregnant controls, however diagnosis is often delayed due to pregnancy-associated gastrointestinal symptoms masking cancer symptoms. A high degree of suspicion, especially in high-risk patients, is the key to early detection and improved prognosis. Digital rectal exams, occult fecal blood tests, and flexible sigmoidoscopy or colonoscopy are performed as indicated. Treatment primarily consists of en-bloc resection of the malignancy and regional lymph nodes; timing of colorectal surgery and delivery are based upon clinical presentation, fetal age, and maternal desires.

Colon cancer during pregnancy. The gastroenterologist's perspective

Colon cancer during pregnancy is uncommon but not rare, with an estimated incidence of several hundred cases per year in the United States. This type of cancer tends to have a poor prognosis that is attributable to delays in diagnosis and advanced disease at diagnosis. The diagnosis frequently is delayed because symptoms of colon cancer, such as rectal bleeding, nausea and vomiting, and constipation, often are attributed to normal pregnancy or minor complications of pregnancy. Pregnancy affects the diagnostic evaluation and therapy of colon cancer because of fetal risks of diagnostic tests and therapy. Appropriate medical evaluation of significant lower gastrointestinal complaints during pregnancy can lead to an earlier and improved diagnosis.

The safety and efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per year have conditions normally evaluated by esophagogastroduodenoscopy (EGD). More than 6000 pregnant patient in the United States per year have conditions normally evaluated by sigmoidoscopy or colonoscopy. Endoscopy during pregnancy raises the unique issue of fetal safety, and endoscopic medications comprise a significant component of fetal risks from endoscopy. This article analyzes the safety of endoscopic medications during pregnancy, reviews the literature on the safety of gastrointestinal endoscopy during pregnancy, proposes guidelines for endoscopic indications during pregnancy, and describes modifications of gastrointestinal endoscopy during pregnancy to increase fetal and maternal safety.

Cancer of the colon, rectum, and anus during pregnancy. The surgeon's perspective

Colorectal carcinoma presenting during pregnancy is uncommon. Most patients present late in pregnancy, and greater than 80% have rectal tumors. Pregnant patients with unexplained rectal bleeding should be evaluated by anorectal examination and flexible sigmoidoscopy. Treatment is individualized to each patient, but a strategy of proceeding immediately with a surgical resection when a diagnosis is made early in pregnancy and allowing the fetus to develop to safe delivery before treating when the diagnosis is made late in pregnancy is recommended. Most patients present with advanced tumors and have a poor prognosis, but prognosis by stage is not different from that in the general population. Adjuvant radiation and chemotherapy have limited roles in the treatment of pregnant women with colon and rectal carcinoma. Future challenges are aimed at improving survival through earlier diagnosis and the development of adjuvant therapies that are effective in patients with advanced disease.

A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups

To analyze the risks versus benefits of flexible sigmoidoscopy and colonoscopy to the pregnant female and fetus, we conducted a multiyear, retrospective study at 10 hospitals of 46 patients undergoing 48 sigmoidoscopies and 8 patients undergoing 8 colonoscopies during pregnancy. Sigmoidoscopy controls included two study control groups and the average American pregnancy outcomes. Sigmoidoscopy indications included hematochezia in 28, diarrhea in 10, abdominal pain in 4, and other in 3. Thirteen patients were in the first trimester of pregnancy, 18 were in the second trimester, and 15 were in the third trimester. Twenty-seven patients had a lesion diagnosed by sigmoidoscopy, including reactivated or newly diagnosed inflammatory bowel disease, bleeding internal hemorrhoids, and other colitidies. Twenty-two of 29 patients with rectal bleeding had a significant lesion identified by sigmoidoscopy. Sigmoidoscopy was significantly more frequently diagnostic for hematochezia than for other indications (p < 0.03, chi2). No endoscopic complications occurred to the pregnant patients. Excluding 4 voluntary abortions and 1 unknown pregnancy outcome, 38 (93%) of 41 pregnant females delivered healthy babies (study control rate = 93%; NS, Fisher's exact test). Mean live-born infant Apgar scores were 8.2+/-1.5 (SD) at 1 min and 9.0+/-0.2 at 5 min (control mean Apgar scores: 8.1+/-1.7 at 1 min and 8.8+/-1.0 at 5 min; NS, Student's t test). Three high-risk pregnancies ended with fetal demise at 8, 9, or 12 weeks after sigmoidoscopy, from causes unrelated to sigmoidoscopy. No fetal cardiac abnormalities were detected by fetal cardiac monitoring during two sigmoidoscopies. Eight pregnant females underwent colonoscopy, without complications. Pregnancy outcomes included six healthy babies delivered at full term, one voluntary abortion, and one fetal demise in a high-risk pregnancy 4 months after colonoscopy from causes unrelated to colonoscopy. This study suggests that sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy may be beneficial in pregnant patients with significant lower gastrointestinal bleeding. Colonoscopy during pregnancy should be considered for life-threatening lower gastrointestinal bleeding or when the only alternative is surgery.

Rectal carcinoma in pregnancy

Rectal carcinoma is an uncommon malignancy in pregnancy. Described below is the case report of a patient with rectal carcinoma diagnosed in pregnancy. together with a review of the current literature. When rectal carcinoma is diagnosed at greater than 20 weeks' gestation the timing and mode of delivery became the major obstetric management decisions. The approaches to these problems are outlined in this report.

Cancer in pregnancy: a review of the literature. Part I

Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.

Gastric cancer in the young, with special reference to 14 pregnancy-associated cases: analysis based on 2,325 consecutive cases of gastric cancer

Clinicopathologic features of gastric cancer in young women were analyzed with special reference to pregnancy (P). Among 2,325 consecutive patients, there were 152 young patients under 40 years of age (57 males and 95 females), and 14 P-associated cases were identified. The male-to-female ratio was 1.7:1.0 on the whole, but 1.0:1.7 in the young group with more females predominating as the age of patients decreased. Among characteristics of gastric cancer in the young females, we noted a significantly higher frequency of both Borrmann type 4 cancer and poorly differentiated adenocarcinoma with the scirrhus type of growth and peritoneal metastasis. These characteristics were more pronounced in the P-associated cases. Although we were unable to determine the mechanism for these tendencies, our findings suggest that the development and growth of gastric cancer in young women may be influenced by their natural, biological and hormonal circumstances. The prognosis of the young women with or without associated pregnancy was good after curative surgery. Both early detection of gastric cancer and subsequent potentially curative surgery are the best ways to obtain good survival for young women, as is the case for members of other age and sex groups.

Bowel obstruction in pregnancy

Intestinal obstruction during pregnancy and in the puerperium is an uncommon complication, although cases are probably underreported. Fortunately, the mortality rate has improved over the decades. Overall, it was greater than 60% in 1900. By the 1930s, maternal mortality had dropped to 21% and fetal mortality decreased to 50%. Modern rates of maternal mortality have shown continued improvement, with Goldthorp reporting an incidence of 12% in 1966. Over the last 30 years the maternal mortality rate has decreased to approximately 6%, as noted in various series published in the English literature. Fetal mortality rates, however, have remained significantly high. They have remained constant at between 20% and 26%. Furthermore, only one third of patients with prenatal bowel obstruction complete term pregnancies after operative resolution of their obstruction. These findings emphasize the importance of remembering that two patients are at risk when intestinal obstruction complicates pregnancy. The delay from presentation to admission and from admission to definitive management continues to be a significant cause of morbidity and mortality. A high index of suspicion is mandated in this patient population, especially in those women presenting with a history of previous abdominal or pelvic surgery. The high incidence of necrotic bowel found in this subset of patients demonstrates the need for aggressive surgical intervention. Only through diligent and urgent intervention can the morbidity and mortality be decreased. The diagnosis and treatment of a pregnant patient suspected of having a bowel obstruction should be no different from those given to a nonpregnant one.

Multicenter, multiyear study of safety and efficacy of flexible sigmoidoscopy during pregnancy in 24 females with follow-up of fetal outcome

Our objectives were to analyze the risks versus benefits of flexible sigmoidoscopy to the pregnant female and fetus. We retrospectively studied 24 consecutive pregnant patients admitted to four university hospitals during seven years who underwent 26 flexible sigmoidoscopies. Sigmoidoscopy indications included hematochezia in 11, diarrhea in 12, abdominal pain in 7, constipation in 2, and occult rectal bleeding in 1. Seven patients were in the first trimester of pregnancy, nine were in the second trimester, and eight were in the third trimester. Sigmoidoscopy provided helpful clinical information in all patients. Twelve patients had a lesion diagnosed by sigmoidoscopy, including reactivation of Crohn's colitis, reactivation of ulcerative colitis, infectious colitis, nonspecific colitis, bleeding internal hemorrhoids, pseudomembranous colitis, anastomotic ulcer, and newly diagnosed Crohn's colitis. In particular, nine of 11 patients with rectal bleeding had a lesion identified by sigmoidoscopy. No endoscopic complications occurred to any pregnant female. Two pregnant patients underwent repeat sigmoidoscopy without complications. Fetal outcome was ascertained in all but one pregnancy. Eighteen pregnant females delivered healthy infants (16 at full term, two at 35 or 36 weeks). Their mean Apgar scores were 8.8 +/- 0.4 SD at 1 min, and 9.0 +/- 0.4 SD at 5 min. One diabetic and hypertensive female suffered an involuntary abortion nine weeks after sigmoidoscopy, which appeared unrelated to the sigmoidoscopy. Four pregnancies were voluntarily aborted. This study suggests that flexible sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy should be considered in medically stable pregnant patients with significant gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy

The pregnant patient afflicted with a variety of colorectal conditions merits special consideration for reasons related to the safety and timeliness of operation while preserving fetal viability and fertility. The literature is scanty with respect to hemorrhoids, fissures, and colorectal and anal carcinoma. Therefore, the patient has to have a forthright discussion with her physician(s) about the pros and cons of operative and nonoperative approaches, which can result in either therapeutic abortion and timely surgery versus preserving the fetus and taking on the unknown factor of whether delay in treatment will cause an adverse outcome. This underscores the need for a frank discussion with the patient with regard to anticipated outcomes. In benign conditions, there is more latitude to adopt a conservative approach, as the patient's ability to tolerate the symptoms of her condition would dictate the need for definitive operative therapy. In the patient with malignancy, delaying surgical or radiation therapy carries an unknown risk to the patient. Here, the patient's personal views regarding abortion and future fertility dictate the timing of definitive treatment.

Rectal carcinoma during pregnancy

Rectal carcinoma presenting during pregnancy is rare with a reported incidence of 0.002%. Management of such an emotionally charged condition can be difficult, especially when the twin goals of curing the disease and preserving the pregnancy are divergent. Four cases of rectal carcinoma presenting during pregnancy are reported. In the first or second trimester of pregnancy, it is possible to resect the tumour with preservation of pregnancy, and in the third trimester, it is best to bring the pregnancy to term before removing the tumour. Unfortunately, the prognosis for such rectal cancer is poor.

Colon and rectal cancer in pregnancy

Colorectal carcinoma presenting in pregnancy is an uncommon disease that is reported to be associated with an extremely poor prognosis. To better characterize this disease, we surveyed the membership of the American Society of Colon and Rectal Surgeons by mailed questionnaire and reviewed the literature. Forty-one new cases of women with large bowel cancer who presented during pregnancy or the immediate postpartum period were identified. The mean age at presentation was 31 years (range, 16-41 years). Tumor distribution was as follows: right colon-3, transverse colon-2, left colon-2, sigmoid colon-8, and rectum-26. Dukes stage at presentation was A = 0, B = 16, C = 17, and D = 6 (two patients were unstaged). Average follow-up was 41 months. Stage for stage, survival was found to be similar to patients with colorectal tumors in the general population. Large bowel cancer coexistent with pregnancy presents in a distal distribution (64 percent of tumors in the current series and 86 percent of those reported in the literature were located in the rectum) and presents at an advanced stage (60 percent were Stage C or more advanced at the time of diagnosis). While patient survival is poor, it is no different stage for stage from the general population with colorectal tumors.

Colon carcinoma during pregnancy: a lethal coincidence

Carcinoma of the colon during pregnancy is rare. A 38-year-old woman with an obstructive adenocarcinoma of the left colon diagnosed at 27 weeks of gestation is described. Three months and 21 months after hemicolectomy a right, subsequently left ovariectomy was performed because of metastatic disease. Three years after initial surgery, which was followed by chemotherapy, the patient died of metastatic disease. Until now 26 cases of colon cancer during pregnancy have been described; none of these patients have survived 5 years. Metastatic spread of colon cancer to the ovaries in pregnant patients is frequently observed (25%). The fetal risk is very small, because placental and fetal involvement in maternal malignancy is rarely observed, even in widespread metastatic disease.