Chemotherapeutic Treatment of Colorectal Cancer in Pregnancy
Chemotherapeutic Treatment of Colorectal Cancer in Pregnancy
A 33-year-old Saudi woman (gravida 9, para 8) presented to our emergency department at 11 weeks of gestation with abdominal pain and increased flatus. The patient had a history of bleeding per rectum for 2½ years, but she believed it was due to hemorrhoids and failed to mention it to her primary care physician. Abdominal ultrasound revealed a complex left ovarian mass (19×12cm) extending up to the epigastrium with hyperechoic solid components, and a small amount of fluid was seen in the pelvis surrounding the appendix. Her hemoglobin was 7.89g/dl, and her hematocrit was 25.2%. The result of a stool test for occult blood was positive, and biochemistry showed iron deficiency anemia. Her cancer antigen 125 (CA-125) level was elevated at 85.4kU/L. She underwent left salpingo-oophorectomy, appendectomy, and partial omentectomy by laparotomy at 13 weeks of gestation. Her pathological examination revealed mucinous adenocarcinoma of the left ovary with signet ring component and serosa positive for tumor deposits, but no lymph node invasion.
The patient was counseled regarding termination of her pregnancy for possible chemotherapy and computed tomography (CT), and she agreed to undergo these interventions. However, after a failed abortion with vaginal administration of methotrexate, she refused further intervention and decided to continue with her pregnancy. Abdominal CT showed a large rectosigmoid tumor measuring 4.2cm×4.7cm×6.3cm with mildly enlarged regional lymph nodes and four hypodense metastatic liver lesions. The patient presented 2 weeks before her next appointment with fresh bleeding per rectum. A colonoscopy revealed a large rectal mass obstructing the lumen. A pathological examination showed fragments of adenomatous mucosa with high-grade dysplasia and foci of possible invasion. Her diagnosis was established as a case of colonic KRAS-mutant positive adenocarcinoma with left ovarian and liver metastases. The patient's case was discussed with maternal-fetal medicine clinicians, and a recommendation was made to start a bimonthly adjuvant FOLFOX-6 chemotherapy regimen consisting of 2-hour infusion of oxaliplatin 100mg/m and leucovorin 200mg/m, 5-fluorouracil (5-FU) 400mg/m bolus, and a 5-FU 2400mg/m 46-hour infusion.
She was started on her first cycle of FOLFOX-6 chemotherapy at 22 weeks. She developed mild peripheral paresthesia in her upper and lower extremities that resolved 3 days after chemotherapy. Her CA-125 level decreased to 29.1kU/L. After five cycles of chemotherapy were completed, abdominal magnetic resonance imaging (MRI) showed an interval reduction of approximately 30% in the size of the previously seen four liver metastatic lesions. There was mild interval reduction in the size of the rectal mass, with almost stable regional lymphadenopathy. The patient completed six cycles of chemotherapy, and a decision was made to withhold further chemotherapy until after delivery. Monthly ultrasound for fetal well-being revealed normal fetal growth and development.
The patient was admitted at 38 weeks of gestation for induction of labor. She had a vaginal delivery of a healthy infant girl of birth weight 2400g with Apgar scores of 9 and 10 at 1 and 5 minutes, respectively. The patient and her infant had no immediate complications post-partum. Two weeks following delivery, the patient received her seventh cycle of FOLFOX-6 chemotherapy. The patient underwent colostomy and cholecystectomy with hepatic metastasectomy followed by six cycles of adjuvant FOLFIRI chemotherapy (folinic acid, 5-fluorouracil and irinotecan). Abdominal and chest CT with intravenous contrast performed at 15 months post-delivery revealed further hepatic lesions, pulmonary nodules and right hydronephrosis caused by a pelvic mass. A decision was made to continue with palliative chemotherapy. Follow-up at 24 months with repeat scans showed evidence of stable hepatic and pulmonary lesions with an interval increase in the size of the patient's pelvic mass. The child was assessed in the pediatric clinic at 1 month and again at 24 months and was found to have met developmental milestones without any recognizable complications, and annual follow-ups were scheduled.
Case Presentation
A 33-year-old Saudi woman (gravida 9, para 8) presented to our emergency department at 11 weeks of gestation with abdominal pain and increased flatus. The patient had a history of bleeding per rectum for 2½ years, but she believed it was due to hemorrhoids and failed to mention it to her primary care physician. Abdominal ultrasound revealed a complex left ovarian mass (19×12cm) extending up to the epigastrium with hyperechoic solid components, and a small amount of fluid was seen in the pelvis surrounding the appendix. Her hemoglobin was 7.89g/dl, and her hematocrit was 25.2%. The result of a stool test for occult blood was positive, and biochemistry showed iron deficiency anemia. Her cancer antigen 125 (CA-125) level was elevated at 85.4kU/L. She underwent left salpingo-oophorectomy, appendectomy, and partial omentectomy by laparotomy at 13 weeks of gestation. Her pathological examination revealed mucinous adenocarcinoma of the left ovary with signet ring component and serosa positive for tumor deposits, but no lymph node invasion.
The patient was counseled regarding termination of her pregnancy for possible chemotherapy and computed tomography (CT), and she agreed to undergo these interventions. However, after a failed abortion with vaginal administration of methotrexate, she refused further intervention and decided to continue with her pregnancy. Abdominal CT showed a large rectosigmoid tumor measuring 4.2cm×4.7cm×6.3cm with mildly enlarged regional lymph nodes and four hypodense metastatic liver lesions. The patient presented 2 weeks before her next appointment with fresh bleeding per rectum. A colonoscopy revealed a large rectal mass obstructing the lumen. A pathological examination showed fragments of adenomatous mucosa with high-grade dysplasia and foci of possible invasion. Her diagnosis was established as a case of colonic KRAS-mutant positive adenocarcinoma with left ovarian and liver metastases. The patient's case was discussed with maternal-fetal medicine clinicians, and a recommendation was made to start a bimonthly adjuvant FOLFOX-6 chemotherapy regimen consisting of 2-hour infusion of oxaliplatin 100mg/m and leucovorin 200mg/m, 5-fluorouracil (5-FU) 400mg/m bolus, and a 5-FU 2400mg/m 46-hour infusion.
She was started on her first cycle of FOLFOX-6 chemotherapy at 22 weeks. She developed mild peripheral paresthesia in her upper and lower extremities that resolved 3 days after chemotherapy. Her CA-125 level decreased to 29.1kU/L. After five cycles of chemotherapy were completed, abdominal magnetic resonance imaging (MRI) showed an interval reduction of approximately 30% in the size of the previously seen four liver metastatic lesions. There was mild interval reduction in the size of the rectal mass, with almost stable regional lymphadenopathy. The patient completed six cycles of chemotherapy, and a decision was made to withhold further chemotherapy until after delivery. Monthly ultrasound for fetal well-being revealed normal fetal growth and development.
The patient was admitted at 38 weeks of gestation for induction of labor. She had a vaginal delivery of a healthy infant girl of birth weight 2400g with Apgar scores of 9 and 10 at 1 and 5 minutes, respectively. The patient and her infant had no immediate complications post-partum. Two weeks following delivery, the patient received her seventh cycle of FOLFOX-6 chemotherapy. The patient underwent colostomy and cholecystectomy with hepatic metastasectomy followed by six cycles of adjuvant FOLFIRI chemotherapy (folinic acid, 5-fluorouracil and irinotecan). Abdominal and chest CT with intravenous contrast performed at 15 months post-delivery revealed further hepatic lesions, pulmonary nodules and right hydronephrosis caused by a pelvic mass. A decision was made to continue with palliative chemotherapy. Follow-up at 24 months with repeat scans showed evidence of stable hepatic and pulmonary lesions with an interval increase in the size of the patient's pelvic mass. The child was assessed in the pediatric clinic at 1 month and again at 24 months and was found to have met developmental milestones without any recognizable complications, and annual follow-ups were scheduled.