Gastric cancer during pregnancy: A report on 13 cases and review of the literature with focus on chemotherapy during pregnancy

Upper Gastrointestinal Tumors during Pregnancy: Diagnosis, Risk Factors, and Treatment Options - A Literature Review

Background

Malignant (and benign) tumors of the upper gastrointestinal tract are very rare in pregnancy and can be difficult to diagnose because their symptoms are often misinterpreted as "typical" symptoms of pregnant women like vomiting, nausea, and reflux. Alterations of the female hormones may affect central aspects, such as modulation of immune response and prognosis.

Summary

Prolonged "pregnancy-associated" symptoms need further diagnostics in all cases. Once diagnosed, treatment of upper gastrointestinal tumors during pregnancy is based on multimodal treatment approaches depending on the gestational age of the pregnancy and the stage of the tumor and may include chemotherapy and radical surgical resection.

Key Message

Only little data exist analyzing the treatment modalities of upper gastrointestinal tumors during pregnancy. Nevertheless, this data demonstrates that curative therapeutic options and guideline-related oncologic concepts can safely be performed in pregnant women. In particular, radical oncologic surgical resection is practicable in different stages of pregnancy and should not be delayed. In any case, decisions in regard to therapy have to be made by a group of specialists taking into account the specific circumstances of the individual patient especially gestational age and tumor stage.

Gastric and Esophageal Cancer in Pregnancy: A Review

Importance

Upper gastrointestinal cancers such as gastric and esophageal cancers are rare malignancies with poor prognosis because it is usually diagnosed in latter stages. Presenting symptoms are frequently presumed pregnancy related rather than malignancy related. This review will raise awareness to consider these aggressive cancers in evaluating gastrointestinal complaints during pregnancy.

Objectives

This review describes pregnancies with gastric and esophageal cancers including presenting symptoms, diagnosis stage, treatments, pregnancy complications, and maternal/fetal outcomes.

Evidence Acquisition

Electronic databases (PubMed/EMBASE) were searched with English language limitation. Search terms, 1970-2023, included "stomach cancer" OR "gastric cancer" AND "etiology" OR "risk factors" OR "diagnosis" OR "treatment" OR "management" OR "prognosis" AND "pregnancy" OR "pregnancy complications" OR "Esophageal Neoplasms" OR "esophageal carcinoma" OR "esophageal malignancy" OR "esophageal cancer" OR "esophageal neoplasm" AND Pregnancy OR "Pregnancy."

Results

Of 611 abstracts reviewed, 63 full articles were identified as the basis of review. Gastric cancer stage was advanced stage III or IV in 88% of patients. Maternal mortality rate was 76%. First-trimester diagnosis occurred in 16%; second, 27%; and third, 18% totaling 61%. Thirty nine percent were found postpartum, postmortem, or undetermined. Ethnic groups most affected were East Asian. Half had cesarean delivery, 29% delivered vaginally, and the rest were not reported. Treatment varied: supportive care only, 8%; chemotherapy only, 34%; and chemotherapy and surgery, 21%. Neonatal outcomes were good overall: 90% survival among cases reported.

Conclusions

Gastric and esophageal cancers are rare and frequently asymptomatic in early stages. When diagnosed in pregnancy, it is usually advanced with poor prognosis and high maternal mortality rate. Diagnostic testing and treatment should proceed as needed during pregnancy with close maternal and fetal surveillance. Abdominal delivery is reserved for usual obstetrical indications.

Relevance

Gastric and esophageal cancers are rare conditions often missed or found late that affect management, mode of delivery, and maternal/fetal outcomes.

Laparoscopic Surgery During Pregnancy: A Meta-Review and Quality Analysis Using the Assessment of Multiple Systematic Reviews (AMSTAR) 2 Instrument

Accumulation of experience with minimally invasive surgery over the last three decades has rendered laparoscopic surgery the mainstay of management for surgical pathology during pregnancy. In the present meta-review, we compiled the available evidence on the safety of laparoscopic and robotic-assisted surgeries during pregnancy, based on relevant systematic reviews (SR) and meta-analyses (MA). A systematic review was performed for articles published until February 2024 in English using PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and Google Scholar based on predefined selection and exclusion criteria. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included SRs and MAs examining women of childbearing age (population) who had undergone laparoscopic surgery or robotic-assisted laparoscopic surgery during pregnancy (intervention). The presence of comparison to open surgery was desirable but not mandatory (comparator). The included studies should necessarily report on fetal loss (outcome), and optionally on other metrics of fetal, maternal, or operative performance. We considered SRs/MAs analyzing randomized trials, observational studies, case reports, and case series (study design). The methodological quality of SRs/MAs not exclusively including case reports and case series was assessed with the Assessment of Multiple Systematic Reviews (AMSTAR) 2 instrument. A total of 1229 articles were screened, of which 78 were potentially eligible. Of these, 33 articles met our inclusion criteria, 18 containing SRs only and 15 SRs with MA. The examined disciplines were laparoscopic appendectomy (10 studies, 30.3%), laparoscopic cerclage for cervical insufficiency (eight studies, 24.2%), adnexal-ovarian laparoscopic surgery (five studies, 15.2%), laparoscopic cholecystectomy and biliary tree exploration (three studies, 9.1%), laparoscopic myomectomy (two studies, 6.1%), and one study each for laparoscopic surgery regarding pancreatic indications, adrenal indications, and bariatric complications (3.0%). The odds ratio/relative risk for fetal loss rate ranged from 0-1.9, with variable statistical significance depending on the discipline. Twenty-three out of the 33 studies were submitted to quality evaluation with the AMSTAR 2 instrument, with three being of "low quality" (13.0%) and the remaining 20 of "critically low quality" (87.0%). In conclusion, the widespread acceptance of laparoscopic surgery for treating surgical pathology during pregnancy is substantiated by heterogeneous and low-quality evidence. Literature mainly revolves around laparoscopic appendectomy, whereas other disciplines that may commonly arise during pregnancy, such as cholecystectomy and the acute abdomen following bariatric surgery, are underrepresented in the literature. Factors such as anatomical alterations that may affect surgical access, surgeon's expertise, and the biological course of the underlying pathology should be taken into consideration when selecting the appropriate mode of operating during pregnancy.

CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Pregnancy, delivery and neonatal outcomes in women with gastrointestinal system cancer in pregnancy. An evaluation of a population database

OBJECTIVES

Gastrointestinal system (GIS) cancer in pregnancy is a rare disease. Our aim was to evaluate the association between this type of cancer and pregnancy, delivery and neonatal outcomes.

METHODS

We conducted a retrospective population-based cohort study using the Healthcare Cost and Utilization Project, Nation-wide Inpatient Sample (HCUP-NIS). We included all women who delivered or had a maternal death in the US between 2004 and 2014. We compared women with an ICD-9 diagnosis of GIS cancer to those without. Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

A total of 9,096,788 women met inclusion criteria. Amongst them, 194 women (2/100,000) had a diagnosis of GIS cancer during pregnancy. Women with GIS cancer, compared to those without, were more likely to be Caucasian, older than 35 years of age, and to suffer from obesity, chronic hypertension, pregestational diabetes and thyroid disease. The cancer group had a lower rate of spontaneous vaginal delivery (aOR 0.2, 95 % CI 0.13-0.27, p<0.001), and a higher rate of preterm delivery (aOR 1.85, 95 % CI 1.21-2.82, p=0.04), and of maternal complications such as blood transfusion (aOR 24.7, 95 % CI 17.11-35.66, p<0.001), disseminated intravascular coagulation (aOR 14.56, 95 % CI 3.56-59.55, p<0.001), venous thromboembolism (aOR 9.4, 95 % CI 2.3-38.42, p=0.002) and maternal death (aOR 8.02, 95 % CI 2.55-25.34, p<0.001). Neonatal outcomes were comparable between the two groups.

CONCLUSIONS

Women with a diagnosis of GIS cancer in pregnancy have a higher incidence of maternal complications including maternal death, without any differences in neonatal outcomes.

Pregnancy and Gastric Cancer: A Narrative Review

Cases of digestive cancers diagnosed during pregnancy are rare. The increasing prevalence of pregnancy in women aged 30-39 years (and not exceptionally 40-49 years) could explain the frequent co-occurrence of cancers and pregnancy. The diagnosis of digestive cancers in pregnancy is difficult due to the overlap between neoplasm symptomatology and the clinical picture of pregnancy. A paraclinical evaluation may also be difficult depending on the trimester of the pregnancy. Diagnosis is also delayed by practitioners' hesitation to use invasive investigations (imaging, endoscopy, etc.) due to fetal safety concerns. Therefore, digestive cancers are often diagnosed during pregnancy in advanced stages, where complications such as occlusions, perforations, and cachexia have already arisen. In this review, we highlight the epidemiology, clinical aspects, paraclinical evaluation, and particularities of the diagnosis and treatment of gastric cancer during pregnancy.

Fetal and placental metastases associated with maternal cancers

PURPOSE

Review the effects of fetal and placental metastases in the setting of maternal cancer.

METHOD

Data reported in the peer-reviewed literature were combined with guidelines to evaluate the incidence, type and prognosis for fetal and placental metastasis in the setting of maternal cancer.

RESULTS

Limited literature available. Fetal and placental metastasis are rare. Fetal metastasis generally occurs on the background of concurrent placental metastasis thus it is important to thoroughly examine the placenta in cases of known gestational cancers. Tumor molecular testing is used to confirm maternal to offspring transmission. Maternal to offspring transmission may have a long timeline between birth to clinical presentation. Prognosis in offspring may be better than in the mother who may have a more aggressive phenotype.

CONCLUSION

Fetal and placental metastasis associated with maternal cancers are rare and limited peer-reviewed literature is available. The occurrence may be confirmed by detailed histological placental evaluation and molecular testing in the offspring.

Gastrointestinal malignancies in pregnancy

Gastrointestinal malignancies, though uncommon in pregnancy, present several unique challenges with regards to diagnosis, staging, and treatment. Imaging the pregnant patient with a suspected or confirmed GI malignancy requires modifications to the radiologic modality of choice and protocol in order to minimize harm to the fetus, ensure accuracy in diagnosis and staging and guide treatment decisions. In this review article, we discuss the imaging approach to the pregnant patient with GI cancer, including safe radiologic modalities and modifications to imaging protocols. We also review the most common GI cancers encountered in pregnancy, including colorectal, pancreatic, gastric, and small bowel tumors, with emphasis to imaging findings, staging, and treatment considerations.

Krukenberg Tumor of Gastric Origin in Pregnant Women with Preeclampsia

Krukenberg tumor refers to a malignancy in the ovary that metastasizes from a primary site, classically the gastrointestinal tract. Pregnancy complicated with a Krukenberg tumor is very rare. In this report, we present two unusual cases of pregnant women with Krukenberg tumors of gastric origin. One case was a full-term pregnant woman with preeclampsia (PE) who underwent a caesarean section when bilateral enlarged ovaries were incidentally identified. Histopathology of the wedge resection biopsy showed single-ring cell carcinoma; this was followed by gastroscopy, which indicated a gastric origin. The woman received chemotherapy but died 6 months later. Another case was a pregnant woman at 30 gestational weeks with abdominal pain complicated with early-onset PE. Ultrasonography and magnetic resonance imaging showed bilateral enlarged ovaries and elevated tumor markers. Gastroscopy indicated linitis plastica. After an emergency caesarean section, adnexectomy was performed, and postoperative histopathology confirmed a Krukenberg tumor. The woman died 2 months after delivery. Gastrointestinal symptoms during pregnancy may indicate a malignancy of rare gastrointestinal origin. PE complicated with Krukenberg tumors in pregnancy should be considered in future studies.

Prognosis, counseling, and indications for termination of pregnancy

As the coincidence of pregnancy and cancer rise, clinicians must be prepared to counsel their patients on the complex relationship between maternal and fetal health. In most types of cancer, maternal prognosis mirrors that of non-pregnant women. However, challenges associated with the timing of diagnosis and treatment can present additional risks. Consequently, pregnant cancer patients must be counseled early and effectively with regard to how their pregnancy status affects treatment options and the range of expected outcomes for both mother and fetus. Some patients choose to terminate pregnancy after such counseling, though the specific course of action depends on the cancer in question, the stage at diagnosis, and the personal priorities and values of the patient.

Tumorigenic mechanisms of estrogen and Helicobacter pylori cytotoxin-associated gene A in estrogen receptor α-positive diffuse-type gastric adenocarcinoma

BACKGROUND

Diffuse-type gastric cancer (DGC), for which Helicobacter pylori infection is a causal factor, is associated with poor prognosis among young women, possibly due to female hormones such as estrogen. We aimed to identify the carcinogenesis induced by estrogen and H. pylori in DGC.

METHODS

We screened and selected estrogen receptor alpha (ERα)-positive (MKN45) and ERα-negative (SNU5) DGC cell lines. H. pylori strain 60190 and its isogenic mutant strain lacking cytotoxin-associated gene A (60190ΔCagA) were used to infect MKN45 cells. And the cytotoxin-related gene A (CagA) cDNA which was cloned into pSP65-SR-HA (cagA-pSP65SRa) vector was used to transfect MKN45 cells. Tumor samples were used for DGC organoid culture.

RESULTS

In MKN45 cells, we found that estradiol promotes epithelial-mesenchymal transition (EMT) and stemness phenotypes via HOTAIR expression. These effects were further enhanced by the addition of CagA secreted by H. pylori but were reversed by co-treatment with fulvestrant (ICI 182,780), a selective ER degrader. We also validated the effect of estrogen on DGC organoids. ERα expression was associated with tumor invasion and HOTAIR expression in DGC patients with overt H. pylori infection.

CONCLUSIONS

These findings may explain the rapid DGC progression in young women with physiologically high levels of estrogen and suggest that fulvestrant with ovarian function suppression could serve as a tumor-suppressive agent in premenopausal patients with DGC.

Efficacy and Safety of Platinum-Based Chemotherapy for Ovarian Cancer During Pregnancy: A Systematic Review and Meta-Analysis

Introduction

Based on the available data on ovarian cancer during pregnancy, we performed a review and meta-analysis to evaluate the efficacy and safety of platinum-based chemotherapy against ovarian cancer during pregnancy.

Methods

We systematically searched three databases including the PubMed, Embase, and Cochrane Library databases for articles published from January 1986 to December 2020 using the following terms: “ovarian tumors OR ovarian carcinoma OR adnexal masses OR ovarian cancer” AND “pregnancy” AND “chemotherapy.” Two authors (Yaping Pei and Yuanfeng Gou) independently searched the literature and extracted data from each eligible study. The outcome measures were overall survival (OS) and progression-free survival (PFS). The OS and PFS of all patients were estimated by Kaplan–Meier survival curves and log-rank tests.

Results

A total of 43 studies including 55 cases of ovarian cancer during pregnancy were selected. Forty-eight patients were comprehensively staged using the International Federation of Gynecology and Obstetrics (FIGO) staging system. Twenty-six of the 48 patients (54.17%) were diagnosed with early-stage disease, while the remaining had advanced stages (II, III, and IV). The mean age at diagnosis was 29.31 years. The majority of patients in this meta-analysis were diagnosed at a mean gestational age of 16.05 weeks. The mean GA at chemotherapy administration was 17.42 weeks. Overall, 55 women gave birth to 56 newborns, including a pair of twins. At the end of follow-up (median 10 months, range 0–73 months), all the children were healthy, except for one child who died 5 days after delivery due to a congenital abnormality. During 2–204 months of follow-up, there were five cases of recurrence, with no evidence of recurrence in the remaining cases. Unfortunately, one patient died 29 months after diagnosis. Neither median overall survival nor median progression-free survival was obtained.

Conclusion

Platinum-based chemotherapy may be a good choice for pregnant women with ovarian cancer who want to continue their pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40487-021-00179-9.

Hepatoid adenocarcinoma of the stomach with PIK3Ca mutation during pregnancy: A case report with molecular profile

Hepatoid adenocarcinoma is an extremely aggressive special subtype of gastric tumors. It can be lethal as no standard treatment options for this type of gastric cancer exist. Here, we describe a very rare case of a young female on her 21^st week of pregnancy who was diagnosed with stage IV hepatoid adenocarcinoma of the stomach with elevated α fetoprotein (AFP) level. Gene mutation analysis performed by next-generation sequencing identified somatic mutations in the PIK3CA gene. Despite the treatment, patient died 2 months after the initial disease presentation. To our best knowledge, this case represents the first report of pregnancy-associated hepatoid gastric adenocarcinoma with the PIK3CA gene mutations, which can provide further clues for the understanding of molecular features of this type of tumor that can reflect biological behavior and may lead to further effective treatment options.

Long-Term Neurodevelopmental Outcome of Children after in Utero Exposure to Chemotherapy

Simple Summary

Facing cancer diagnosis during pregnancy constitutes a truly complex and challenging situation for both the patients and the physicians. Cancer diagnosis in a period of hope and joy is an unendurable situation that may affect the psychosocial functioning of the mother, causing depression, anxiety, self-blame, and social isolation. At the same time, a moral dilemma evolves among medical professionals; what is best for the mother in terms of immediate chemotherapy may have detrimental effects on the fetus, and conversely, delaying therapy and protecting the fetus may have a negative impact on the mother as the tumor progresses. Solid data on the safety profile or risks of anti-cancer agents and on the long-term neurodevelopmental outcome of children after in utero exposure to chemotherapy may provide both the patients and the physicians the information necessary for shared decision making when cancer is diagnosed during pregnancy.

Abstract

Pregnancy-related cancer management represents a real challenge for both the patients and the physicians. The long-term neurodevelopmental outcome of children in utero exposed to chemotherapeutic agents has only recently been addressed. This review aims to systematically integrate and highlight all existing data from the literature regarding the effect of prenatal exposure to chemotherapy on fetal brain growth and child development. All eligible studies are based on validated neurodevelopmental testing scales (e.g., Bayley Scales of Infant Development, Wechsler Preschool and Primary Scale of Intelligence) and/or well-defined questionnaires. Our systematic review including 17 studies demonstrates that no major consequences on the neurodevelopment of children after in utero exposure to anti-cancer drugs have been reported; nevertheless, longer and more thorough follow-up with large-scale multicenter prospective studies is certainly required in order to draw firm conclusions.

Postpartum Involution and Cancer: An Opportunity for Targeted Breast Cancer Prevention and Treatments?

Childbirth at any age confers a transient increased risk for breast cancer in the first decade postpartum and this window of adverse effect extends over two decades in women with late-age first childbirth (>35 years of age). Crossover to the protective effect of pregnancy is dependent on age at first pregnancy, with young mothers receiving the most benefit. Furthermore, breast cancer diagnosis during the 5- to 10-year postpartum window associates with high risk for subsequent metastatic disease. Notably, lactation has been shown to be protective against breast cancer incidence overall, with varying degrees of protection by race, multiparity, and lifetime duration of lactation. An effect for lactation on breast cancer outcome after diagnosis has not been described. We discuss the most recent data and mechanistic insights underlying these epidemiologic findings. Postpartum involution of the breast has been identified as a key mediator of the increased risk for metastasis in women diagnosed within 5-10 years of a completed pregnancy. During breast involution, immune avoidance, increased lymphatic network, extracellular matrix remodeling, and increased seeding to the liver and lymph node work as interconnected pathways, leading to the adverse effect of a postpartum diagnosis. We al discuss a novel mechanism underlying the protective effect of breastfeeding. Collectively, these mechanistic insights offer potential therapeutic avenues for the prevention and/or improved treatment of postpartum breast cancer.

Gastric cancer during pregnancy: A report on 13 cases and review of the literature with focus on chemotherapy during pregnancy

Introduction

Gastric cancer during pregnancy is extremely rare and data on optimal treatment and possible chemotherapeutic regimens are scarce. The aim of this study is to describe the obstetric and maternal outcome of women with gastric cancer during pregnancy and review the literature on antenatal chemotherapy for gastric cancer.

Material and methods

Treatment and outcome of patients registered in the International Network on Cancer, Infertility and Pregnancy database with gastric cancer diagnosed during pregnancy were analyzed.

Results

In total, 13 women with gastric cancer during pregnancy were registered between 2002 and 2018. Median gestational age at diagnosis was 22 weeks (range 6‐30 weeks). Twelve women were diagnosed with advanced disease and died within 2 years after pregnancy, most within 6 months. In total, eight out of 10 live births ended in a preterm delivery because of preeclampsia, maternal deterioration, or therapy planning. Two out of six women who initiated chemotherapy during pregnancy delivered at term. Two neonates prenatally exposed to chemotherapy were growth restricted and one of them developed a systemic infection with brain abscess after preterm delivery for preeclampsia 2 weeks after chemotherapy. No malformations were reported.

Conclusions

The prognosis of gastric cancer during pregnancy is poor, mainly due to advanced disease at diagnosis, emphasizing the need for early diagnosis. Antenatal chemotherapy can be considered to reach fetal maturity, taking possible complications such as growth restriction, preterm delivery, and hematopoietic suppression at birth into account.