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Inicio Cirugía Española (English Edition) Pancreatic Adenocarcinoma During Pregnancy
Journal Information
Vol. 93. Issue 7.
Pages 479-481 (August - September 2015)
Vol. 93. Issue 7.
Pages 479-481 (August - September 2015)
Scientific letter
DOI: 10.1016/j.cireng.2013.04.018
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Pancreatic Adenocarcinoma During Pregnancy
Adenocarcinoma pancreático durante el embarazo
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María Labarca-Acosta, Eduardo Reyna-Villasmil
Corresponding author
sippenbauch@gmail.com

Corresponding author.
, Jhoan Aragón-Charris, Joel Santos-Bolívar
Servicio de Obstetricia y Ginecología, Maternidad Dr. Nerio Belloso, Hospital Central Dr. Urquinaona, Maracaibo, Estado Zulia, Venezuela
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Table 1. Reports of Pancreatic Adenocarcinoma During Pregnancy.
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Malignant tumours occur in 0.1% of pregnant women. The most common types are cervical, breast, melanoma, lymphoma and leukaemia.1 Pancreatic cancer is unusual in women of child-bearing age.2 The average age for the diagnosis of pancreatic ductal adenocarcinoma is 72, and less than 3% of diagnosed patients are under the age of 45.3 We present a case of pancreatic adenocarcinoma during pregnancy.

The patient is a 35-year-old woman who had had 2 pregnancies, 1 normal delivery, and was at 16 weeks gestation. She presented with vomiting, pain in the left epigastrium and hypochondrium, general weakness and weight loss. Physical examination revealed a painful abdomen with positive Murphy sign and normal vitals. Lab results were: haemoglobin 8.6g/dL, total bilirubin 2.49mg/dL, direct bilirubin 1.4mg/dL, aspartate aminotransferase 120IU/L, alanine aminotransferase 125IU/L, phosphatase alcaline 313IU/L, serum amylase 136IU/L and urine amylase 426IU/L.

Abdominal ultrasound reported the absence of cholelithiasis or choledocholithiasis and multiple hypodense liver masses. Fine-needle biopsy demonstrated the presence of cells compatible with adenocarcinoma of the pancreas.

Tumour marker levels were: CA15-3, 36U/mL; carcinoembryonic antigen, 860ng/mL; CA19-9, 2750U/mL; and CA125, 2221U/mL. Endoscopic ultrasound demonstrated metastatic liver disease, several lymphadenopathies and a neoplastic mass in the tail of the pancreas measuring 40mm in diameter with central necrosis. Magnetic resonance confirmed the existence of an area of necrosis measuring 2cm×3cm in the pancreas, lesions in the liver and several lymphadenopathies in the hepatic-pancreatic hilum (Fig. 1).

Fig. 1.

Magnetic resonance of the upper abdomen where the arrows indicate an area of central necrosis of the pancreas (right) and metastatic lesions in the liver (left).

(0.1MB).

Six days later, obstetric ultrasound confirmed the death of the foetus. Uterine evacuation obtained a foetus weighing 120g, followed by curettage.

The patient was discharged on the third day to later initiate outpatient chemotherapy, but she died 26 days later. The pathology study demonstrated the presence of a poorly differentiated adenocarcinoma of the pancreas. The tumour was larger than 6cm in diameter, with extension beyond the pancreas towards the lymph nodes and perineural invasion.

Although the exact cause is unknown, pancreatic cancer has several risk factors that have been identified (older age, male sex, diabetes, obesity, chronic pancreatitis and smoking).3 Certain genetic syndromes and germline mutations have been associated with cancer: familial atypical multiple mole melanoma, Peutz-Jeghers syndrome, hereditary pancreatitis, etc. However, these cases have been estimated to represent less than 20% of hereditary pancreatic cancer cases.2,3

In the present case, the pancreatic lesion was able to be identified by ultrasound since the uterus was not so large as to displace the organs or impede visualisation of the pancreas. Computed tomography and magnetic resonance are not limited by the size of the uterus or foetus and should be used for the diagnosis of pancreatic disease during pregnancy.4 Endoscopic retrograde cholangiopancreatography is used for the diagnosis and treatment of pancreatic tumours that cause obstructive jaundice, and it has been used during pregnancy. This technique should be considered for biliary drainage if surgery is not indicated or in pregnant women with jaundice.3

In pregnant patients with pain in the upper right abdomen and a large mass near the liver, CA19-9 concentrations should be measured. CA19-9 concentrations are useful in the diagnosis of pancreatic adenocarcinoma without jaundice in which a cut value of 100U/mL has provided a sensitivity of 55% and a specificity of 99%.5 CA19-9 levels are unaffected by pregnancy and can confirm the presence of malignant disease.4,6,7

The prognosis of pancreatic adenocarcinoma during pregnancy, particularly in resectable cases, is unknown because most patients have advanced disease.7Table 1 summarises the published reports of pancreatic adenocarcinomas during pregnancy. Kazoka et al.2 reported a case of pancreatic adenocarcinoma during pregnancy and reviewed another 6 patients, 5 of whom died within the following 3 months due to advanced and unresectable disease. The patient of the case reported herein had an unresectable tumour and died within 3 months of the diagnosis.

Table 1.

Reports of Pancreatic Adenocarcinoma During Pregnancy.

No.  Year  Gestational age at presentation  Gestational age at time of surgery  Complications 
1992  28 weeks  30 weeks  Hypercoagulability 
1995  16 weeks  16 weeks  Bile duct obstruction, metastasis 
1997  14 weeks  17 weeks  Jaundice 
2006  27 weeks  Postpartum  Pancreatitis, jaundice, lung and liver metastases 
2007  30 weeks  Not available  Restricted intrauterine growth of the foetus, metastases 
2009  24 weeks  Postpartum  Pancreatitis 
2010  30 weeks  34 weeks  Gastric perforation 
2011  16 weeks  18 weeks  Bile duct obstruction, metastasis 
2011  19 weeks  20 weeks  None 
10  2011  37 weeks  Postpartum  Pulmonary embolism, thrombosis 
11  2011  17 weeks  19 weeks  Metastasis 

The 2 most important factors for determining the treatment strategy for pancreatic adenocarcinoma during pregnancy are disease stage and gestational age. In patients with a resectable mass in the first trimester of pregnancy, delayed surgery can lead to the lesion becoming unresectable, which would reduce survival.2 Pancreaticoduodenectomy can be performed during pregnancy since the risk of mortality associated with surgery is lower than 2%, even though the morbidity rates are high (close to 50%), while the 5-year survival rate after pancreatic cancer surgery is about 15%.3,6,7

Treatment with chemotherapy and radiotherapy is an additional therapeutic consideration for the management of pancreatic cancer as either adjuvant or neoadjuvant therapy, but there are obvious limitations during pregnancy.8,9 Most patients are not physically prepared to initiate treatment until 6 weeks after resection, during which time the disease has the chance to progress.2,7,8

References
[1]
D. Pereg, G. Koren, M. Lishner.
Cancer in pregnancy: gaps, challenges and solutions.
Cancer Treat Rev, 34 (2008), pp. 302-312
[2]
R.M. Kakoza, C.M. Vollmer, K.E. Stuart, T. Takoudes, D.W. Hanto.
Pancreatic adenocarcinoma in the pregnant patient: a case report and literature review.
J Gastrointest Surg, 13 (2009), pp. 535-541
[3]
F. Eckel, G. Schneider, R.M. Schmid.
Pancreatic cancer: a review of recent advances.
Expert Opin Investig Drugs, 15 (2006), pp. 1395-1410
[4]
D. Perera, R. Kandavar, E. Palacios.
Pancreatic adenocarcinoma presenting as acute pancreatitis during pregnancy: clinical and radiologic manifestations.
J La State Med Soc, 163 (2011), pp. 114-117
[5]
M.G. Schlieman, H.S. Ho, R.J. Bold.
Utility of tumor markers in determining resectability of pancreatic cancer.
Arch Surg, 138 (2003), pp. 951-955
[6]
T. Onuma, Y. Yoshida, T. Yamamoto, F. Kotsuji.
Diagnosis and management of pancreatic carcinoma during pregnancy.
Obstet Gynecol, 116 (2010), pp. 518-520
[7]
C.A. Boyd, J. Benarroch-Gampel, G. Kilic, E.J. Kruse, S.M. Weber, T.S. Riall.
Pancreatic neoplasms in pregnancy: diagnosis, complications, and management.
J Gastrointest Surg, 16 (2012), pp. 1064-1071
[8]
S. Lubner, B. Hall, D. Gopal, A. Soni, R. Hegeman, N. Winterle, 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, 2 (2011), pp. 258-261
[9]
E. Cardonick, A. Iacobucci.
Use of chemotherapy during human pregnancy.
Lancet Oncol, 5 (2004), pp. 283-291

Please cite this article as: Labarca-Acosta M, Reyna-Villasmil E, Aragón-Charris J, Santos-Bolívar J. Adenocarcinoma pancreático durante el embarazo. Cir Esp. 2015;93:475–477.

Copyright © 2013. AEC
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