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CASE REPORT
Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 138-141

Carcinoma stomach in pregnancy: Report of a rare association


Department of Surgery, Unit 1 – General Head and Neck Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission26-Nov-2019
Date of Decision26-Dec-2019
Date of Acceptance09-Feb-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Prof. Pranay Gaikwad
Department of Surgery, Unit 1 – General Head and Neck Surgery, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_64_19

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  Abstract 

The occurrence of gastric cancer in pregnancy is rare and can potentially have devastating effects on both the mother and the fetus. There is often a delay in the diagnosis as the symptoms during pregnancy may confuse the presentation and may be overlooked. Not unexpectedly, gastric cancer in pregnancy is diagnosed at its late or advanced stage. In addition, in the presence of a live fetus, there is an ethical component to the decision-making for the best possible course of treatment. Treating physicians need to consider several factors such as the optimal surgical outcome, maternal safety, fetal safety, and prevention of miscarriage or preterm labor. This dilemma continues even postoperatively to decide on the further course of the treatment as indicated through several multi-disciplinary tumor board meetings to decide on the timings of the delivery, induction of labor, and adjuvant chemotherapy. We report the case of a 23-year-old female patient who presented with vomiting and loss of weight at 22 weeks of gestation was diagnosed to have poorly differentiated gastric cancer and underwent subtotal gastrectomy at 25 weeks of gestation. The article reviews the association of gastric cancer with pregnancy, discussing the pathogenesis and management of such a case.

Keywords: Carcinoma stomach, gastrectomy, pregnancy


How to cite this article:
Ambrose NP, Gaikwad P. Carcinoma stomach in pregnancy: Report of a rare association. Curr Med Issues 2020;18:138-41

How to cite this URL:
Ambrose NP, Gaikwad P. Carcinoma stomach in pregnancy: Report of a rare association. Curr Med Issues [serial online] 2020 [cited 2020 Nov 26];18:138-41. Available from: https://www.cmijournal.org/text.asp?2020/18/2/138/282785




  Introduction Top


Carcinoma of the stomach is considered extremely rare during pregnancy, occurring in only 0.025%–0.1% among all pregnancies.[1] The common malignancies associated with pregnancy include malignant melanoma, breast cancer, cervical cancer, lymphoma, ovarian cancer, gastrointestinal cancer, and genitourinary cancer.[2] In pregnancy, there is a delay in the diagnosis due to the similarity of pregnancy-related symptoms, and hence, the diagnosis of gastric cancer is at its advanced stage, thereby showing a dismal prognosis. In a study conducted by Sakamoto et al., among the 137 cases of pregnancy-associated gastric cancer from Japan, with respect to the stage of gastric cancer, 92.5% of the patients had advanced gastric cancer, and only 45.3% underwent gastrectomy.[3] Similarly, the prognosis was very poor. The 1-year and 2-year survival rates were 18% and 15.1%, respectively.[3] We present the case of a female patient in the second trimester of pregnancy with features of gastric outlet obstruction due to the carcinoma of the stomach that surgically.


  Case Report Top


A 23-year-old female with an obstetric score of G4P2L2A1 presented to the outpatient clinic at 22 weeks of gestation with a 3-month history of vomiting and loss of weight. She predominantly complained of postprandial nonbilious vomiting that occurred a few minutes after meals and contained undigested food particles associated with a loss of 23 kg weight over the past 3 months. She did not have a history of malignancies in the family. On examination, she had a generalized wasting with the pulse rate of 92/min and the blood pressure of 90/60 mm of Hg. Abdominal examination revealed the palpable gravid uterus consistent with 20 weeks of gestation. There was no umbilical nodule, rectal nodules, left supraclavicular adenopathy, or any other signs of disseminated malignancy. The rest of the examination was normal.

Hemogram revealed Hb of 10.0 g/dL, platelets of 72,000/mm[3], and the white cell counts within the normal range. The serum biochemistry revealed sodium 137 mmol/L, potassium 3.5 mmol/L, and creatinine 0.35 mg%. In lieu of her pregnancy, she underwent a magnetic resonance imaging of the abdomen and pelvis that showed asymmetrical mural thickening in the antrum of the stomach with perigastric fat stranding and features of gastric outlet obstruction. No obvious perigastric or para-aortic nodes were noted [Figure 1].
Figure 1: Magnetic resonance imaging of the abdomen showing asymmetrical T2 hypointense annular mural thickening in the antrum of the stomach with perigastric fat stranding and features of gastric outlet obstruction.

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Upper gastrointestinal endoscopy showed an ulcer in the prepyloric region with necrotic base and raised margins, a biopsy from the ulcer was taken, and a nasojejunal tube was placed in situ to administer enteral nutrition [Figure 2].
Figure 2: Upper gastrointestinal endoscopy image showing an ulcer in the prepyloric region with a necrotic base and raised margins (black arrowhead).

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The endoscopic biopsy from the prepyloric ulcer was reported as moderately differentiated adenocarcinoma. She was discussed in a multidisciplinary tumor board (MDT) and posted for surgery after taking written informed consent for the procedure and intraoperative photographs for academic purposes. Intraoperatively, the gravid uterus was noted up to the level of the umbilicus, a 3 cm × 3 cm ulcerated lesion with surrounding induration was seen in the prepyloric region with multiple nodes at stations 3, 4, 5, 6, and 7. She underwent a subtotal gastrectomy [Figure 3].
Figure 3: (a) Gravid uterus (black arrowhead) and distended thick-walled stomach (white arrowhead). (b) Resected gastrectomy specimen with the lesion (nontoothed forceps).

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Her postoperative period was uneventful, and she was taking a normal diet at discharge on the 9th postoperative day. Surgical biopsy was reported as poorly differentiated adenocarcinoma, antrum, and pylorus pT4aN2M0. Postoperatively, her case was rediscussed in the MDT board, and she was planned for adjuvant chemotherapy. The patient and her relatives wished to continue adjuvant chemotherapy in their hometown.

Over the telephonic follow-up, she had delivered at full term and was started on adjuvant chemotherapy. In January 2020, she completed four cycles of uneventful adjuvant chemotherapy and is due for a follow-up in a month. The patient has been followed up for 7 months, with no serious adverse reaction during the adjuvant treatment.


  Discussion Top


Gastric cancer in pregnancy is extremely rare during pregnancy, and in patients younger than 40 years, gastric carcinoma tends to be poorly differentiated with overall poor prognosis.[4]

The pathogenesis of pregnancy-related gastric cancer is a matter of discussion. Jaspers et al. suggested that the clinical features and prognosis rates in carcinoma stomach during pregnancy did not differ from those in other younger patients.[5] Furthermore, the Helicobacter pylori infection rate is higher in pregnant women than in nonpregnant women to a significant extent comparing 26.6% versus 11%.[6] Furukawa et al. suggested that there is an accelerated growth of stomach cancer cells in pregnancy.[7] Neoplastic cell growth appears to be favored in an environment rich in estrogen hormone, as evidenced in studies with positive estrogen receptor in 55.8% of gastric tumors.[8] Harrison et al. suggested that estrogen receptor status is an independent factor in gastric cancer.[8] In pregnancy, the spread of cancer can be facilitated by the increased circulatory flow during pregnancy.[9]

The management of pregnancy, including termination of pregnancy, depends on gestational age and stage of the disease with no clear treatment guidelines. Furthermore, there are no data to suggest that termination of pregnancy alters the biological behavior of the tumor or the patient's prognosis with appropriate antineoplastic therapy.[10]

Due to delayed diagnosis of gastric cancer in pregnancy, upper digestive endoscopy is considered the method of choice in these cases due to its low risk during pregnancy and if possible should be performed in the second trimester of pregnancy.[11]

Surgery is considered safe in pregnancy in all trimesters.[10] When the surgery is considered the optimal method for treatment, it should be performed in the second trimester. At this time, the uterus is not so large to make surgery technically difficult.[12] Four important factors that need to be taken into consideration for any surgical intervention during pregnancy include the optimal surgical outcome, maternal safety, fetal safety, and prevention of miscarriage or preterm labor.[12]

Ueo et al. in a review of 61 pregnant patients with gastric cancer reported that only 47.5% of patients underwent surgery and those who underwent surgery had a high incidence of in-hospital death (22.7%) and a poor prognosis, with a 3-year survival rate of 21.1%.[13] Sakamoto et al., among the 137 cases of pregnancy-associated gastric cancer from Japan, with respect to the stage of gastric cancer, 92.5% of the patients had advanced gastric cancer, and only 45.3% underwent gastrectomy.[3] Similarly, the prognosis was very poor – the 1- and 2-year survival rates were 18% and 15.1%, respectively.[3]

Chemotherapeutic agents are generally considered safe after the first trimester and should be avoided 3 weeks before the resolution time due to the risk of hematological toxicity and fetal immunosuppression.[14]


  Conclusion Top


Gastric cancer in pregnancy is extremely rare, and the diagnosis is at an advanced stage due to symptoms that are frequently observed in pregnancy. Although extremely rare, it should be considered in the differential diagnosis, especially in patients who have risk factors with repetitive vomiting and symptoms of cachexia. The treatment decision should take into consideration the clinical stage as well as the gestational age at the diagnosis. A multidisciplinary approach, with medical oncologists, surgeons, and obstetricians becomes essential for appropriate therapeutic decision-making in this difficult and rare scenario.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Fully institutional.

Conflicts of interest

There are no conflicts of interest.

Ethical statement

The authors mentioned in the manuscript have agreed for the order of authorship, read and approved the manuscript, and given consent for submission and subsequent publication of the manuscript. The corresponding author takes full ownership for all the communication related to the manuscript.



 
  References Top

1.
Pacheco S, Norero E, Canales C, Martínez JM, Herrera ME, Muñoz C, et al. The rare and challenging presentation of gastric cancer during pregnancy: A report of three cases. J Gastric Cancer 2016;16:271-6.  Back to cited text no. 1
    
2.
Lee HJ, Lee IK, Kim JW, Lee KU, Choe KJ, Yang HK. Clinical characteristics of gastric cancer associated with pregnancy. Dig Surg 2009;26:31-6.  Back to cited text no. 2
    
3.
Sakamoto K, Kanda T, Ohashi M, Kurabayashi T, Serikawa T, Matsunaga M, et al. Management of patients with pregnancy-associated gastric cancer in Japan: A mini-review. Int J Clin Oncol 2009;14:392-6.  Back to cited text no. 3
    
4.
Rugge M, Busatto G, Cassaro M, Shiao YH, Russo V, Leandro G, et al. Patients younger than 40 years with gastric carcinoma: Helicobacter pylori genotype and associated gastritis phenotype. Cancer 1999;85:2506-11.  Back to cited text no. 4
    
5.
Jaspers VK, Gillessen A, Quakernack K. Gastric cancer in pregnancy: Do pregnancy, age or female sex alter the prognosis? Case reports and review. Eur J Obstet Gynecol Reprod Biol 1999;87:13-22.  Back to cited text no. 5
    
6.
Lanciers S, Despinasse B, Mehta DI, Blecker U. Increased susceptibility to Helicobacter pylori infection in pregnancy. Infect Dis Obstet Gynecol 1999;7:195-8.  Back to cited text no. 6
    
7.
Furukawa H, Iwanaga T, Hiratsuka M, Imaoka S, Ishikawa O, Kabuto T, et al. Gastric cancer in young adults: Growth accelerating effect of pregnancy and delivery. J Surg Oncol 1994;55:3-6.  Back to cited text no. 7
    
8.
Harrison JD, Morris DL, Ellis IO, Jones JA, Jackson I. The effect of tamoxifen and estrogen receptor status on survival in gastric carcinoma. Cancer 1989;64:1007-10.  Back to cited text no. 8
    
9.
Barbosa OA, de Souza AD, Moura MR, Junior EJ, Fontenele JP, Chaves FF, et al. Diffuse gastric cancer during pregnancy: Report of a rare association. World J Oncol 2015;6:456-8.  Back to cited text no. 9
    
10.
Basta P, Bak A, Roszkowski K. Cancer treatment in pregnant women. Contemp Oncol (Pozn) 2015;19:354-60.  Back to cited text no. 10
    
11.
O'Mahony S. Endoscopy in pregnancy. Best Pract Res Clin Gastroenterol 2007;21:893-9.  Back to cited text no. 11
    
12.
Albright CM, Wenstrom KD. Malignancies in pregnancy. Best Pract Res Clin Obstet Gynaecol 2016;33:2-18.  Back to cited text no. 12
    
13.
Ueo H, Matsuoka H, Tamura S, Sato K, Tsunematsu Y, Kato T. Prognosis in gastric cancer associated with pregnancy. World J Surg 1991;15:293-7.  Back to cited text no. 13
    
14.
Amant F, Han SN, Gziri MM, Vandenbroucke T, Verheecke M, van Calsteren K. Management of cancer in pregnancy. Best Pract Res Clin Obstet Gynaecol 2015;29:741-53.  Back to cited text no. 14
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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