Pregnancy-Associated Cancer: A Case Report of a Gastric Cancer Diagnosis in the III Trimester of Pregnancy and Subsequent Management

Case Report

Austin Gynecol Case Rep. 2023; 8(3): 1047.

Pregnancy-Associated Cancer: A Case Report of a Gastric Cancer Diagnosis in the III Trimester of Pregnancy and Subsequent Management

Sabattini A*; Morano D; Greco P

Department of Medical Sciences, Institute of Obstetrics and Gynecology, University of Ferrara, Italy

*Corresponding author: Sabattini A Department of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44124 Ferrara, Italy. Tel: 3495416311 Email: ariannasabattini.doc@gmail.com

Received: November 22, 2023 Accepted: December 18, 2023 Published: December 23, 2023

Abstract

The co-occurrence of gastric carcinoma and pregnancy is very rare event. Diagnosis is often delayed, frequently at an advanced stage due to the nonspecific symptomatology, which can be confused with the normal physiological symptoms of pregnancy. Therefore, a multidisciplinary approach is essential to initiate the treatment of maternal pathology as early as possible, with the goal of delivering at a moderately preterm gestation age to ensure favorable neonatal outcome.

We present a case of gastric carcinoma diagnosed during the third trimester, where the earliest presentation included liver metastases, and the primary tumor’s location was unknown. Throughout our observation period, we conduced clinical-laboratory monitoring, a preliminary radiological staging of the illness (considering the limitations imposed by pregnancy), and a histological diagnosis with biopsy sampling. An elective cesarean section was performed in the moderately preterm period, following the completion of Respiratory Distress Syndrome (RDS) prophylaxis.

Case Report

A 38-year-old female, in her third pregnancy and secondipara (with two previous C-sections), presented for detection during the third-trimester ultrasound of a vascularized intrahepatic lesion measuring approximately 6 cm. The lesion was tender to palpation and of unclear interpretation, prompting an urgent surgical evaluation. During anamnesis, the patient reported experiencing persistent nausea and vomiting since the beginning of pregnancy, along with cramp-like pains in the right hypochondrium that radiated to the epigastric region over the past 10 days. Additionally, the patient noted the development of a hard, wood-like nodule in the right hypochondrium that was tender to palpation.

Our OB/GYN ER requested a complete abdominal ultrasound, hematological and chemical exams, and a gastroenterologic consultation. The abdominal ultrasound revealed a liver with altered echotexture due to multiple heterogeneous rounded iso-hyperechoic formations, some with a hypoechoic center, ranging in size from a minimum of 2 to a maximum of 5 cm in the right lobe. Focal biliary tract ectasis was noted, altering the hepatic profile at the VIII-VI segment. In the epigastrium, at the level of the celiac trunk, various rounded formations were observed, partly converging, with a maximum diameter of 6 cm.

The gastroenterologic consultation recommended an evaluation, with a thorough risk-benefit analysis, to determine the necessity for histological characterization through an ultrasound-guided hepatic biopsy. Hematochemical exams revealed microcytic anemia (Hgb 7.2g/dL; MCV 60 fl), average platelet levels (323000/microL), and a slight alteration in hepatic functioning (AST 44 U/L; ALT 33 U/L) with normal serum bilirubin.

Obstetric ultrasound and cardiotocographic monitoring yielded results within the normal range. The patient was admitted to the Obstetrics ward for the continuation of the diagnostic and treatment process.

During the hospitalization, tumor markers were measured, with the following results: alpha-fetoprotein 26510 ng/mL (n.v. in non-pregnant women <10); Ca 125 12565 U/mL (n.v. <35); CEA >1000 ng/mL (n.v. <5); NSE 19.6 microg/L (n.v. <18.3 microg/L); Ca 19.9 10 U/L (n.v. <37).

To obtain a histologic sample, an ultrasound-guided hepatic biopsy was performed using an intercostal approach on a lesion at the V hepatic segment, followed by histological analysis.

To identify the primary tumor, in consultation with Oncology, we conducted an abdominal MRI with/without contrast agents, revealing: “Numerous lesions of rounded appearance distributed throughout the liver parenchyma, some with central lesion necrosis, of probable substitute-replicative significance (the larger ones approximately 65x55 mm and 63x55 mm). In the retroperitoneal region, the gastrohepatic omentum, and along the mesenteric vascular pedicle, numerous and

sometimes voluminous solid, possibly neoplastic lesions were observed, some with internal necrotic components (with major elements respectively in the right paracaval site 80x64 mm, along the small gastric curvature 96x53 mm, and in the mesenteric adipose tissue 66x53 mm). These lesions appear to be indicative of lymphadenopathy. The gastric antrum wall appears significantly thickened and slightly hyperemic; these findings, though not unequivocal, seem to warrant an endoscopic targeted evaluation aimed at excluding the possibility of a primary tumor at this level.”