Title

Advanced Colorectal cancer in pregnancy; a case report.

Objectives:

Colorectal cancer is a rare condition in childbearing women, with an incidence of about 2.2-7.7 per 100,000 pregnancies. Here, we report a case of CRC in pregnancy, with diagnosis of metastatic adenocarcinoma of colon, who underwent laparotomy with caesarean delivery and creation of ileostomy, had palliative care, culminating in end-of-life support at our hospital.

Case Report

This is a case of 41 yrs. old Primigravida, White British, BMI 22, booked under Obstetrician-led care, commenced on low-dose aspirin and iron tablets as her booking Hb was 109g/dl. She self-referred to her GP at around 26 weeks, with worsening exhaustion, breathlessness and on and off constipation.

Additional bloods including LFTs were performed and found to be deranged, ALP 986micromol/L, Bilirubin 29micromol/L, ALT 42iu/L. Urgent Ultrasound abdomen suggested multiple focal lesions on the liver, with possibility of liver secondaries. Of note were her raised CA 19-9: > 10000, CEA 93ng/ml and CA 125 of 121U/ml. She mentioned that her father was undergoing treatment for Prostate cancer and that she was a Pescatarian.

MRI abdomen and pelvis reported extensive hepatic metastatic disease with appearances of obstructing mid/distal ascending colon primary tumour. There was early involvement of the  multidisciplinary team, who opined against chemotherapy in view of extensive hepatic metastasis. She underwent Elective laparotomy with caesarean delivery, creation of ileostomy at around 28 weeks and 3 days gestation as there was persistent foetal tachycardia on the CTG the previous day. The mother’s condition deteriorated rapidly thereafter and 23 days following the birth of the baby she was placed onto an end-of life care pathway. She died the following day surrounded by her family.

Discussion

CRC in pregnancy presents with non-specific symptoms such as nausea, vomiting, abdominal pain, constipation, anaemia, and rectal bleeding which are attributed to general pregnancy symptoms2. Hence, the women are often diagnosed with advanced or metastatic disease. Auxiliary examinations such as X-ray, ultrasound, sigmoidoscopy, and MRI are relatively safe during pregnancy, while CT, barium enema and radioisotope scanning may have adverse effects on the foetus due to ionizing radiation. For this mother, MDM reported histology result as moderately differentiated mucinous carcinoma of colorectal origin; tumour grade T3 N1 M1, with Dukes’s D surgical pathological staging.

Conclusion

CRC poses diagnostic and therapeutic challenges during pregnancy. A multidisciplinary approach, requiring collaboration between the obstetric, surgical, oncology, neonatology teams, as well as social workers, chaplains and ethicists is required.

References