http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–4 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1049942
SHORT REPORT
Metastatic pancreatic adenocarcinoma presented as back pain in pregnancy: case report and review of literature
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
Man-Wa Lui, Carman Wing Sze Lai, and Charas Yeu-Theng Ong Department of Obstetrics and Gynecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
Abstract
Keywords
Objective: To report a case of pancreatic adenocarcinoma complicating pregnancy with a review of literature. Methods: A literature search of all English articles on pancreatic adenocarcinoma in pregnancy till December 2014. Results: A 35-year-old patient presented at 22 weeks of gestation for back pain and weight loss. Subsequent she was confirmed to have metastatic pancreatic adenocarcinoma. There were in total eleven case reports identified. Abdominal pain and back pain were the presenting symptoms in 75% and 33.3% of patients respectively. Conclusions: Pancreatic adecnocarcinoma is a rare cancer in pregnancy. A high index of suspicion is required in case of atypical symptoms.
Malignancy in pregnancy, metastatic cancer, palliative care, pancreatic adenocarcinoma, pancreatic cancer
Introduction Pancreatic cancer is a rare but lethal malignancy. It is the fourth leading cause of cancer death in the United States [1]. The median survival of metastatic pancreatic cancer is 3–6 months [1]. Patients usually present at late stage due to nonspecific symptoms. It is uncommon in pregnant women with only a small number of case reports available.
Case presentation A 35-year-old patient, gravida 3, para 1, presented with back pain during the index pregnancy. She had history of normal vaginal delivery three years earlier. Her past health was unremarkable. Routine antenatal checkups in regional hospital including Down’s syndrome screening and fetal morphology scan were normal. She had started to experience back pain in the lumbar region since 22 weeks of gestation, which was debilitating and persistent despite physiotherapy and regular use of analgesics. She also complained of significant weight loss of around 20 pounds in a matter of five months. She was thus referred to an orthopedics surgeon. The clinical examination was unremarkable, but she had a Magnetic Resonance Imaging (MRI) spine performed due to the severity of the pain (Figure 1). She was anemic with hemoglobin level of 7.4 g/dL with presence of occult blood in stool. Physical examination was unremarkable. Magnetic resonance imaging (MRI) of spine at Address for correspondence: Man-Wa Lui, Room 528, Block K, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. Tel: +852 22554647. Fax: +852 28550947. E-mail: [email protected]
History Received 13 February 2015 Accepted 7 May 2015 Published online 11 June 2015
26 weeks of gestation showed mild disc dehydration at L4-5 only but with presence of multiple retroperitoneal lymphadenopathy in the upper abdomen. The initial differential diagnoses were lymphoma, metastatic lymphadenopathy or tuberculosis. Carcinoembryonic antigen (CEA) was elevated to 404 ng/ml (reference range 53.0 ng/ml) and CA19.9 was 40 U/ml (reference range 537 U/ml). Bone marrow aspirate and trephine showed no evidence of abnormal cellular infiltration. MRI abdomen and pelvis without contrast showed an eight-centimeter mass arising from the pancreatic body and extending into tail. The lesion appears to be abutting onto abdominal wall. Ultrasonography-guided biopsy of the mass confirmed ductal adenocarcinoma of pancreas. Incidental finding of short and dilated cervix was noted and the cervix was 2 cm dilated when she presented to our unit at 27 weeks of gestation. A course of corticosteroids was administrated due to the risk of pre-term birth. After reviewing of the case at multidisciplinary meeting with hepatobiliary surgeon, oncologist, obstetrician and neonatologist, option of neoadjuvant chemotherapy or expectant management prior to delivery discussed with patient as the disease was likely to be inoperable. She was assessed by pain team and started on Codeine, Morphine and Gabapentin. Patient opted for induction of labor at 30 + 4 weeks of gestation due to suboptimal control of back pain and significant psychological stress. A baby girl, weighing 1160 g with Apgar score 6 at 1 min and 9 at 5 min was delivered vaginally. Positron emission tomography and contrast computer tomography of abdomen performed after delivery revealed liver metastasis. Celiac plexus block was performed for better
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
2
M.-W. Lui et al.
Figure 1. Magnetic resonance imaging of abdomen at 28 weeks of gestation revealed 8 cm pancreatic mass extending to the tail of the pancreas (upper – T1 weighted, lower – T2 weighted).
pain control. Palliative chemotherapy (Folfirinox with 80% dose of Oxaliplatin and Irinotecan with 50% of Fluorouracil) was started for stage IV pancreatic cancer. Later, it was switched to combination of Gemcitabine, AbrazaneÕ (albumin-bounded Paclitaxel) and Erlotinib after six cycles due to intolerable vomiting. Repeated computer tomography showed increasing in size of the pancreatic tumor up to 12 cm. Patient subsequently opted for palliative care and succumbed five months after delivery.
Discussion Pancreatic adenocarcinoma complicating pregnancy is rare. We searched the English literature on pancreatic adenocarcinoma and pregnancy, and identified eleven cases [2–12]. Table 1 presents the summary of the cases. The median age at presentation was 37 ± 3 years old (range: 25–40) and the median gestation at presentation was 24 ± 9.5 weeks (range: 16–35). It tends to present only at advance stage when there is invasion to surrounding organs or metastasis has occurred. Only four patients were able to receive curative treatments. Seven out of twelve patients succumbed within six months after delivery. Abdominal pain occurred in 75% of patients (9/12 patients) and is the most common presenting symptoms. Nausea and vomiting (41.7%, 5/12 patients), back pain (33.3%, 4/12 patients) and weight loss (33.3%, 4/12 patients) are also typical symptoms of pancreatic tumor, however, these symptoms are non-specific. Some may present with
J Matern Fetal Neonatal Med, Early Online: 1–4
obstructive jaundice, gastric outlet obstruction, or symptoms of metastatic disease. Rarely, patient may presented with newly diagnosed diabetes mellitus or impaired glucose tolerance. Back pain is a very common minor aliment in pregnancy and occurs in up to 45% of women [13]. Pregnancy-related low back pain usually starts at 18 weeks of gestation. Musculoskeletal pain is a common cause of low back pain in pregnancy. As being mechanical in nature, it is typically improve with rest and aggregated by movements. Simple analgesics and physiotherapy are usually adequate for pain control. However, this should be a symptom not to be overlooked. In the presence of atypical symptoms or warning signs including constitutional symptoms, debilitating pain requiring regular use of analgesics or presence of neurological symptoms, further investigations should be carried out to exclude any underlying conditions. Assessment by orthopedic surgeon or imaging including MRI may be warranted. Ultrasound scan still remains as the first line imaging investigation of abdominal mass in pregnant women as being non-ionizing radiation. Non-contrast MRI is gaining popularity due to better delineation of soft tissue structures and bowels without excessive risk on pregnancies. Assessment for vascular involvement is of utmost important in pancreatic cancer as surgery is the only curative treatment option. However, it is often suboptimal in pregnancy due to use of non-contrast imaging. There were concerns on the use of contrast medium in pregnant women, though there was no reported case of fetal teratogenic effect with the use of gadolinium contrast [14]. If contrast imaging is deemed necessary in pregnancy, the use of lowest dose of gadolinium can be considered. Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic options especially for patients presenting with obstructive jaundice. Though it can be safely used in pregnancy, it is associated with higher risk of post-ERCP pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive alternative, however, it is not therapeutic and tissue biopsy cannot be obtained. Staging laparotomy has been reported to be performed in pregnant women up to 25 weeks of gestation [15]. During the workup for lymphadenopathy, elevated CEA and CA19.9 raised the concern of adenocarcinoma from gastrointestinal tract in origin initially. Pregnancy was shown not to have any significant effect on the level of CEA and CA19.9 at first and second trimester [16]. Though both would slightly increase in the third trimester, it would still be within the normal range. As a result, a grossly elevated level of CEA or CA19.9 should raise the concern of underlying malignancies from the gastrointestinal tract. It was also shown that elevated CEA is a poor prognostic indicator for pancreatic cancer [17]. Treatment for pancreatic adenocarcinoma in pregnancy is controversial and depends on gestation at presentation, stage of disease, presence of complications and maternal condition. There were two reported cases of performance of curative surgery at early second trimester and one of the patients received post-operative chemotherapy in addition [8,9]. It is, however, limited by the presence of gravid uterus, suboptimal staging of disease and late presentation.
37
32
39
37
38
37
40
37
32
36
25
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
20
35
34
16
24
22
27
2nd trimester
16
14
24
Gestation (weeks)
Epigastric pain, vomiting
Epigastric pain, vomiting, weight loss
RUQ pain with acute abdomen
Epigastric pain, nausea, vomiting, weight loss Back pain, nausea, vomiting, jaundice
RUQ pain and anorexia Abdominal pain, fatty stool alternating with constipation Epigastric pain, nausea, vomiting, upper lumbar backache, jaundice Epigastric pain
Right chondral pain, epigastric discomfort, weight loss Back pain, nausea, jaundice
Presenting symptoms
USG, MRI, MRCP, ERCP and liver biopsy
USG/CT and exploratory laparotomy after delivery
CT
ERCP, non-contrast MRI, staging laparoscopy
MRCP and USGguided liver biopsy ERCP with duodenal mucosal biopsy
ERCP and MRI
Exploratory laparotomy N/A
ERCP and exploratory laparotomy
ERCP and exploratory laparotomy
Diagnosis
Nil
Pancreaticoduodenectomy, cholecystectomy at 18weeks, gemcitabine from 24–31weeks pancreaticoduodenectomy with repair of stomach perforation at CS Nil
Percutaneous cholecystostomy tube
Nil
Cholecystostomy as palliative treatment at 24 weeks Curative pylorus-preserving surgery at 17 weeks Palliative bypass surgery at 20 weeks Hysterectomy and pancreatic resection at CS Trans-abdominal cholecystostomy (palliative)
Treatment (during pregnancy)
Cholecystectomy, retrocolic gastrojejunostomy and biliary bypass; followed by chemotherapy Nil
Chemotherapy
Palliative chemotherapy Whipple operation, followed by chemotherapy Salvage regimen of chemotherapy
Died 12 months after diagnosis
Vaginal delivery at 35 weeks
Died two weeks after delivery
Stable disease 12 months after diagnosis
CS at 35 weeks
CS at 30 weeks
Remain disease free for 26 months
CS at 34 weeks
CS at 28 weeks
Died four weeks after diagnosis Died 6months after surgery
Died a few weeks after delivery Alive as of date of publication (unknown interval) Died 50 days after delivery
Remain well three months after delivery
Died three months after delivery
Maternal outcome
TOP at 24 weeks
CS at 28 weeks
CS
N/A
Nil
CS at 28 weeks
N/A
CS at 32 weeks
Mode of delivery
Nil
N/A
Palliative bypass surgery
Treatment after delivery
N/A
Healthy female
Healthy male
Healthy male, normal development at two years old
Healthy female
N/A
Live newborn female before resection (during 2nd trimester) Healthy female delivered
Healthy male
Normally developed fetus three months postop
Healthy twin
Fetal outcome
CS – Caesarean section, CT – computer tomography, ERCP – endoscopic retrograde cholangiopancreatography, USG – ultrasonography, NA – not available, MRI – magnetic resonance imaging, MRCP – magnetic resonance cholangiopancreatography, RUQ – right upper quadrant, TOP – termination of pregnancy.
Age
Case (references)
Table 1. Summary of reported cases of pancreatic adenocarcinoma in pregnancy.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
DOI: 10.3109/14767058.2015.1049942
Pancreatic cancer in pregnancy 3
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
4
M.-W. Lui et al.
Palliative treatment with symptomatic relief remains the main stay of treatment during pregnancy. Bypass surgeries are commonly performed for relieving of biliary obstruction. Effective pain management and psychological support remain a fundamental part of palliative treatment. Cancer pain in pancreatic cancer is often devastating. Medications including Morphine, Gabapentin may not be effective and use of nerve block would be considered. Earlier delivery may be considered in case of advance gestation with balancing of fetal maturity and stage of disease. Mode of delivery depends on gestation, maternal disease control and presence of obstetrics indications. Though vaginal delivery is not contraindicated, it should be balanced with both the physical and psychological stress of vaginal delivery. Nearly all patients had Caesarean section and one patient opted for termination of pregnancy. Our patient was only the second reported case having vaginal delivery. There is still no effective protocol for screening and identification of early stage pancreatic cancer. Presentation of pancreatic cancer in pregnancy can be rather non-specific and thus pose a challenge in diagnosis and management. Albeit challenging, it is still possible with a high degree of suspicion to diagnose pancreatic cancer in pregnancy, and to optimally manage with this rare disease with support from multidisciplinary team.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.
References 1. Vincent A, Herman J, Schulick R, et al. Pancreatic cancer. Lancet 2011;378:607–20. 2. Gamberdella FR. Pancreatic carcinoma in pregnancy: a case report. Am J Obstet Gynecol 1984;149:15–17.
J Matern Fetal Neonatal Med, Early Online: 1–4
3. Blackbourne LH, Jones RS, Catalano C, et al. Pancreatic adenocarcinoma in the pregnant patient. Cancer 1997;79:1776–9. 4. Simchuk 3rd E, Welch J, Orlando 3rd R. Antepartum diagnosis of pancreatic carcinoma: a case report. Conn Med. 1995;59: 259–62. 5. Gojnic M, Boskovic V, Fazlagic A, et al. Pancreatic tumor in a pregnant woman: a rare case report. Eur J Gynaecol Oncol 2004;26: 221–4. 6. Marinoni E, Di Netta T, Caramanico L, et al. Metastatic pancreatic cancer in late pregnancy: a case report and review of the literature. J Matern Fetal Neonatal Med 2006;19:247–9. 7. Lin Su L, Biswas A, Wee A, Sufyan W. Placental metastases from pancreatic adenocarcinoma in pregnancy. Acta Obstet Gynecol Scand 2006;85:626–7. 8. Kakoza RM, Vollmer Jr CM, Stuart KE, et al. Pancreatic adenocarcinoma in the pregnant patient: a case report and literature review. J Gastrointest Surg 2009;13:535–41. 9. Lubner S, Hall B, Gopal D, et al. A 37 year-old pregnant woman with pancreatic adeno-carcinoma treated with surgery and adjuvant chemotherapy: a case report and literature review. J Gastrointest Oncol 2011;2:258–61. 10. Onuma T, Yoshida Y, Yamamoto T, Kotsuji F. Diagnosis and management of pancreatic carcinoma during pregnancy. Obstet Gynecol 2010;116:518–20. 11. Marci R, Pansini G, Zavatta C, et al. Pancreatic cancer with liver metastases in a pregnant patient: case report and review of the literature. Clin Exp Obstet Gynecol 2011;39:127–30. 12. Perera D, Kandavar R, Palacios E. Pancreatic adenocarcinoma presenting as acute pancreatitis during pregnancy: clinical and radiologic manifestations. J LA State Med Soc 2011;163:4–117. 13. Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Pract 2010;10:60–71. 14. Webb JA, Thomsen HS. Gadolinium contrast media during pregnancy and lactation. Acta Radiol 2013;54:599–600. 15. Ruano R, Hase EA, Bernini C, et al. Pancreaticoduodenectomy as treatment of adenocarcinoma of the papilla of Vater diagnosed during pregnancy. A case report. J Reprod Med 2001; 46:1021–4. 16. Ercan S, Kaymaz O, Yucel N, Orcun A. Serum concentrations of CA 125, CA 15-3, CA 19-9 and CEA in normal pregnancy: a longitudinal study. Arch Gynecol Obstet 2012;285:579–84. 17. Lee KJ, Yi SW, Chung MJ, et al. Serum CA 19-9 and CEA levels as a prognostic factor in pancreatic adenocarcinoma. Yonsei Med J 2013;54:643–9.
SHORT REPORT
Metastatic pancreatic adenocarcinoma presented as back pain in pregnancy: case report and review of literature
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
Man-Wa Lui, Carman Wing Sze Lai, and Charas Yeu-Theng Ong Department of Obstetrics and Gynecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
Abstract
Keywords
Objective: To report a case of pancreatic adenocarcinoma complicating pregnancy with a review of literature. Methods: A literature search of all English articles on pancreatic adenocarcinoma in pregnancy till December 2014. Results: A 35-year-old patient presented at 22 weeks of gestation for back pain and weight loss. Subsequent she was confirmed to have metastatic pancreatic adenocarcinoma. There were in total eleven case reports identified. Abdominal pain and back pain were the presenting symptoms in 75% and 33.3% of patients respectively. Conclusions: Pancreatic adecnocarcinoma is a rare cancer in pregnancy. A high index of suspicion is required in case of atypical symptoms.
Malignancy in pregnancy, metastatic cancer, palliative care, pancreatic adenocarcinoma, pancreatic cancer
Introduction Pancreatic cancer is a rare but lethal malignancy. It is the fourth leading cause of cancer death in the United States [1]. The median survival of metastatic pancreatic cancer is 3–6 months [1]. Patients usually present at late stage due to nonspecific symptoms. It is uncommon in pregnant women with only a small number of case reports available.
Case presentation A 35-year-old patient, gravida 3, para 1, presented with back pain during the index pregnancy. She had history of normal vaginal delivery three years earlier. Her past health was unremarkable. Routine antenatal checkups in regional hospital including Down’s syndrome screening and fetal morphology scan were normal. She had started to experience back pain in the lumbar region since 22 weeks of gestation, which was debilitating and persistent despite physiotherapy and regular use of analgesics. She also complained of significant weight loss of around 20 pounds in a matter of five months. She was thus referred to an orthopedics surgeon. The clinical examination was unremarkable, but she had a Magnetic Resonance Imaging (MRI) spine performed due to the severity of the pain (Figure 1). She was anemic with hemoglobin level of 7.4 g/dL with presence of occult blood in stool. Physical examination was unremarkable. Magnetic resonance imaging (MRI) of spine at Address for correspondence: Man-Wa Lui, Room 528, Block K, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. Tel: +852 22554647. Fax: +852 28550947. E-mail: [email protected]
History Received 13 February 2015 Accepted 7 May 2015 Published online 11 June 2015
26 weeks of gestation showed mild disc dehydration at L4-5 only but with presence of multiple retroperitoneal lymphadenopathy in the upper abdomen. The initial differential diagnoses were lymphoma, metastatic lymphadenopathy or tuberculosis. Carcinoembryonic antigen (CEA) was elevated to 404 ng/ml (reference range 53.0 ng/ml) and CA19.9 was 40 U/ml (reference range 537 U/ml). Bone marrow aspirate and trephine showed no evidence of abnormal cellular infiltration. MRI abdomen and pelvis without contrast showed an eight-centimeter mass arising from the pancreatic body and extending into tail. The lesion appears to be abutting onto abdominal wall. Ultrasonography-guided biopsy of the mass confirmed ductal adenocarcinoma of pancreas. Incidental finding of short and dilated cervix was noted and the cervix was 2 cm dilated when she presented to our unit at 27 weeks of gestation. A course of corticosteroids was administrated due to the risk of pre-term birth. After reviewing of the case at multidisciplinary meeting with hepatobiliary surgeon, oncologist, obstetrician and neonatologist, option of neoadjuvant chemotherapy or expectant management prior to delivery discussed with patient as the disease was likely to be inoperable. She was assessed by pain team and started on Codeine, Morphine and Gabapentin. Patient opted for induction of labor at 30 + 4 weeks of gestation due to suboptimal control of back pain and significant psychological stress. A baby girl, weighing 1160 g with Apgar score 6 at 1 min and 9 at 5 min was delivered vaginally. Positron emission tomography and contrast computer tomography of abdomen performed after delivery revealed liver metastasis. Celiac plexus block was performed for better
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
2
M.-W. Lui et al.
Figure 1. Magnetic resonance imaging of abdomen at 28 weeks of gestation revealed 8 cm pancreatic mass extending to the tail of the pancreas (upper – T1 weighted, lower – T2 weighted).
pain control. Palliative chemotherapy (Folfirinox with 80% dose of Oxaliplatin and Irinotecan with 50% of Fluorouracil) was started for stage IV pancreatic cancer. Later, it was switched to combination of Gemcitabine, AbrazaneÕ (albumin-bounded Paclitaxel) and Erlotinib after six cycles due to intolerable vomiting. Repeated computer tomography showed increasing in size of the pancreatic tumor up to 12 cm. Patient subsequently opted for palliative care and succumbed five months after delivery.
Discussion Pancreatic adenocarcinoma complicating pregnancy is rare. We searched the English literature on pancreatic adenocarcinoma and pregnancy, and identified eleven cases [2–12]. Table 1 presents the summary of the cases. The median age at presentation was 37 ± 3 years old (range: 25–40) and the median gestation at presentation was 24 ± 9.5 weeks (range: 16–35). It tends to present only at advance stage when there is invasion to surrounding organs or metastasis has occurred. Only four patients were able to receive curative treatments. Seven out of twelve patients succumbed within six months after delivery. Abdominal pain occurred in 75% of patients (9/12 patients) and is the most common presenting symptoms. Nausea and vomiting (41.7%, 5/12 patients), back pain (33.3%, 4/12 patients) and weight loss (33.3%, 4/12 patients) are also typical symptoms of pancreatic tumor, however, these symptoms are non-specific. Some may present with
J Matern Fetal Neonatal Med, Early Online: 1–4
obstructive jaundice, gastric outlet obstruction, or symptoms of metastatic disease. Rarely, patient may presented with newly diagnosed diabetes mellitus or impaired glucose tolerance. Back pain is a very common minor aliment in pregnancy and occurs in up to 45% of women [13]. Pregnancy-related low back pain usually starts at 18 weeks of gestation. Musculoskeletal pain is a common cause of low back pain in pregnancy. As being mechanical in nature, it is typically improve with rest and aggregated by movements. Simple analgesics and physiotherapy are usually adequate for pain control. However, this should be a symptom not to be overlooked. In the presence of atypical symptoms or warning signs including constitutional symptoms, debilitating pain requiring regular use of analgesics or presence of neurological symptoms, further investigations should be carried out to exclude any underlying conditions. Assessment by orthopedic surgeon or imaging including MRI may be warranted. Ultrasound scan still remains as the first line imaging investigation of abdominal mass in pregnant women as being non-ionizing radiation. Non-contrast MRI is gaining popularity due to better delineation of soft tissue structures and bowels without excessive risk on pregnancies. Assessment for vascular involvement is of utmost important in pancreatic cancer as surgery is the only curative treatment option. However, it is often suboptimal in pregnancy due to use of non-contrast imaging. There were concerns on the use of contrast medium in pregnant women, though there was no reported case of fetal teratogenic effect with the use of gadolinium contrast [14]. If contrast imaging is deemed necessary in pregnancy, the use of lowest dose of gadolinium can be considered. Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic options especially for patients presenting with obstructive jaundice. Though it can be safely used in pregnancy, it is associated with higher risk of post-ERCP pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive alternative, however, it is not therapeutic and tissue biopsy cannot be obtained. Staging laparotomy has been reported to be performed in pregnant women up to 25 weeks of gestation [15]. During the workup for lymphadenopathy, elevated CEA and CA19.9 raised the concern of adenocarcinoma from gastrointestinal tract in origin initially. Pregnancy was shown not to have any significant effect on the level of CEA and CA19.9 at first and second trimester [16]. Though both would slightly increase in the third trimester, it would still be within the normal range. As a result, a grossly elevated level of CEA or CA19.9 should raise the concern of underlying malignancies from the gastrointestinal tract. It was also shown that elevated CEA is a poor prognostic indicator for pancreatic cancer [17]. Treatment for pancreatic adenocarcinoma in pregnancy is controversial and depends on gestation at presentation, stage of disease, presence of complications and maternal condition. There were two reported cases of performance of curative surgery at early second trimester and one of the patients received post-operative chemotherapy in addition [8,9]. It is, however, limited by the presence of gravid uterus, suboptimal staging of disease and late presentation.
37
32
39
37
38
37
40
37
32
36
25
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
20
35
34
16
24
22
27
2nd trimester
16
14
24
Gestation (weeks)
Epigastric pain, vomiting
Epigastric pain, vomiting, weight loss
RUQ pain with acute abdomen
Epigastric pain, nausea, vomiting, weight loss Back pain, nausea, vomiting, jaundice
RUQ pain and anorexia Abdominal pain, fatty stool alternating with constipation Epigastric pain, nausea, vomiting, upper lumbar backache, jaundice Epigastric pain
Right chondral pain, epigastric discomfort, weight loss Back pain, nausea, jaundice
Presenting symptoms
USG, MRI, MRCP, ERCP and liver biopsy
USG/CT and exploratory laparotomy after delivery
CT
ERCP, non-contrast MRI, staging laparoscopy
MRCP and USGguided liver biopsy ERCP with duodenal mucosal biopsy
ERCP and MRI
Exploratory laparotomy N/A
ERCP and exploratory laparotomy
ERCP and exploratory laparotomy
Diagnosis
Nil
Pancreaticoduodenectomy, cholecystectomy at 18weeks, gemcitabine from 24–31weeks pancreaticoduodenectomy with repair of stomach perforation at CS Nil
Percutaneous cholecystostomy tube
Nil
Cholecystostomy as palliative treatment at 24 weeks Curative pylorus-preserving surgery at 17 weeks Palliative bypass surgery at 20 weeks Hysterectomy and pancreatic resection at CS Trans-abdominal cholecystostomy (palliative)
Treatment (during pregnancy)
Cholecystectomy, retrocolic gastrojejunostomy and biliary bypass; followed by chemotherapy Nil
Chemotherapy
Palliative chemotherapy Whipple operation, followed by chemotherapy Salvage regimen of chemotherapy
Died 12 months after diagnosis
Vaginal delivery at 35 weeks
Died two weeks after delivery
Stable disease 12 months after diagnosis
CS at 35 weeks
CS at 30 weeks
Remain disease free for 26 months
CS at 34 weeks
CS at 28 weeks
Died four weeks after diagnosis Died 6months after surgery
Died a few weeks after delivery Alive as of date of publication (unknown interval) Died 50 days after delivery
Remain well three months after delivery
Died three months after delivery
Maternal outcome
TOP at 24 weeks
CS at 28 weeks
CS
N/A
Nil
CS at 28 weeks
N/A
CS at 32 weeks
Mode of delivery
Nil
N/A
Palliative bypass surgery
Treatment after delivery
N/A
Healthy female
Healthy male
Healthy male, normal development at two years old
Healthy female
N/A
Live newborn female before resection (during 2nd trimester) Healthy female delivered
Healthy male
Normally developed fetus three months postop
Healthy twin
Fetal outcome
CS – Caesarean section, CT – computer tomography, ERCP – endoscopic retrograde cholangiopancreatography, USG – ultrasonography, NA – not available, MRI – magnetic resonance imaging, MRCP – magnetic resonance cholangiopancreatography, RUQ – right upper quadrant, TOP – termination of pregnancy.
Age
Case (references)
Table 1. Summary of reported cases of pancreatic adenocarcinoma in pregnancy.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
DOI: 10.3109/14767058.2015.1049942
Pancreatic cancer in pregnancy 3
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/18/15 For personal use only.
4
M.-W. Lui et al.
Palliative treatment with symptomatic relief remains the main stay of treatment during pregnancy. Bypass surgeries are commonly performed for relieving of biliary obstruction. Effective pain management and psychological support remain a fundamental part of palliative treatment. Cancer pain in pancreatic cancer is often devastating. Medications including Morphine, Gabapentin may not be effective and use of nerve block would be considered. Earlier delivery may be considered in case of advance gestation with balancing of fetal maturity and stage of disease. Mode of delivery depends on gestation, maternal disease control and presence of obstetrics indications. Though vaginal delivery is not contraindicated, it should be balanced with both the physical and psychological stress of vaginal delivery. Nearly all patients had Caesarean section and one patient opted for termination of pregnancy. Our patient was only the second reported case having vaginal delivery. There is still no effective protocol for screening and identification of early stage pancreatic cancer. Presentation of pancreatic cancer in pregnancy can be rather non-specific and thus pose a challenge in diagnosis and management. Albeit challenging, it is still possible with a high degree of suspicion to diagnose pancreatic cancer in pregnancy, and to optimally manage with this rare disease with support from multidisciplinary team.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.
References 1. Vincent A, Herman J, Schulick R, et al. Pancreatic cancer. Lancet 2011;378:607–20. 2. Gamberdella FR. Pancreatic carcinoma in pregnancy: a case report. Am J Obstet Gynecol 1984;149:15–17.
J Matern Fetal Neonatal Med, Early Online: 1–4
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