Colon cancer is a rare diagnosis in 30-year-old women, which may be further complicated by their concurrent gravid status. Several physiological changes that occur during an intrauterine pregnancy (IUP) can mask symptoms of early colon cancer. Our patient was a 30-year-old, Gravida 2, Para 0 woman with an uncomplicated pregnancy until the 35th week of gestation when she developed preeclampsia and symptoms suggestive of early hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome. Following induction of labor and the subsequent, uncomplicated vaginal delivery, the patient developed symptoms of nausea, vomiting, and constipation with abdominal pain and bloating. Abdominal computed tomography (CT) revealed a large mass in the right colon along with the involvement of periaortic lymph nodes and the presence of liver metastases. Hepatic metastases were possibly responsible for the patient’s elevated liver enzyme levels, which were initially considered to have been caused by HELLP syndrome because the patient also had preeclampsia. The rarity of colon cancer in young, pregnant patients with no family history, such as in this case, results in poor prognosis owing to nonspecific symptoms of the developing malignancy being attributed to pregnancy, which further delays diagnosis and subsequent therapy. Of 29 cases of colon cancer in pregnant patients recorded till date, this is the first report of a stage 4 adenocarcinoma of the colon with hepatic metastasis, elevated liver enzyme levels, and increased blood pressure with associated preeclampsia, which was diagnosed in the postpartum period. It may be important to consider broader differential diagnoses in expectant patients presenting with unusual and persistent symptoms.
Colon cancer is rare in young adults, and its occurrence in a 30-year-old pregnant patient with no family history prevented its early diagnosis [
A pregnant, 30-year-old G2P0L0 Caucasian woman presented to her obstetrician at 35 weeks and 3 days of gestation with elevated blood pressure in the range of 180s/100 and was referred to labor and delivery triage. Upon admission, a preeclampsia workup was initiated, during which her blood pressure reading was 182/92. A complete blood count (CBC) and urinalysis (to assess the presence of microalbumin and creatinine) were performed. Her protein/creatinine ratio was 1.12. A complete metabolic panel (CMP) report revealed elevated liver enzymes including aspartate transaminase (AST) and alanine transaminase (ALT) at levels of 155(normal range, 15-37) U/L and 84 (normal range, 12-78) U/L, respectively. The CBC report showed a hemoglobin level of 11.7 (normal range, 11.7-15.5) gm/dL with hematocrit of 35.3 (normal range, 33.0-45.0) %. The total bilirubin level was 0.70 (normal range, 0.0-1.0) mg/dL, and the urinalysis was negative for the presence of any bilirubin or red blood cells (RBCs). Considering her clinical presentation and laboratory findings, the patient was diagnosed with preeclampsia. Furthermore, while the patient’s platelet count was not reduced (281 (normal range, 130-400) K/mm3), the possibility of developing HELLP syndrome or its incomplete presentation was suspected owing to her elevated liver enzyme levels. The patient was induced and experienced an uncomplicated and short labor followed by a normal, vaginal delivery. The neonate was monitored in the neonatal intensive care unit (NICU) for 24 hours, which were uneventful.
During the <72-hour postpartum period, the patient began to complain of abdominal discomfort, bloating, nausea, and constipation. On postpartum day 1, the patient was started on magnesium sulfate infusion for 24 hours for seizure prophylaxis and was also started on labetalol, which was continued throughout the hospital stay, for a presumptive preeclampsia. CBC and CMP were repeated, which showed a hemoglobin level of 8.7 gm/dL and a hematocrit of 25.9%. The platelet count increased to 389K/mm3, and her AST and ALT levels were 66 U/L and 41 U/L, respectively. These symptoms and lab values are atypical for a postpartum patient, even if they had been diagnosed with preeclampsia or HELLP syndrome, and with the lack of improvement following delivery along with a rising platelet count, it was decided that further investigation was necessary. On postpartum day 6, the patient was obstipated and had not had a bowel movement in 12 days, which prompted an abdominal radiograph. This showed dilated loops of small and large bowel. General surgery was then consulted, and further imaging was ordered. Abdominal and chest computed tomography (CT) revealed a large,
Computed tomography scan showing a mass in hepatic flexure of the colon.
Computed tomography scan showing liver metastasis along with retroperitoneal, mesenteric, and celiac lymphadenopathy.
Due to the size of the tumor and the fact that tumor debulking would delay our patient getting started with chemotherapy, it was decided that a palliative ileostomy would be most appropriate and debulking would be held off until a later date, if at all. With a stage 4 adenocarcinoma, the utmost importance is starting chemotherapy in a timely fashion. The palliative diverting ileostomy was performed on the following day. The patient’s postoperative course was uncomplicated, and the ileostomy was functional. The patient was urgently referred to an oncologist and has since begun combination chemotherapy with fluorouracil, leucovorin, irinotecan, and bevacizumab.
The patient’s carcinoembryonic antigen (CEA) level, assessed before discharge, was elevated at 266.0 (normal range, ≤3) ng/mL.
The patient provided informed consent for the publication of her medical information in this case report.
In a review of 29 reported cases of colorectal cancer (CRC) in pregnant patients, Heise et al. reported that the primary tumor most commonly involved the sigmoid colon. While two of the reported patients had developed the primary CRC in the hepatic flexure, they were diagnosed in the antepartum period (i.e., at 18 and 24 weeks of gestation) and were therefore able to consult an oncologist and receive early, systematic treatment [
Diagnosing colon cancer was challenging in a 30-year-old patient with no family history or known risk factors and presenting with vague symptoms, which could be easily confused with GI complaints commonly associated with a normal, intrauterine pregnancy. The incidence of colon cancer is very low in patients in their childbearing years. This can cause such patients’ symptoms to be initially ignored, which can result in a definitive diagnosis at a later stage, when the malignancy is usually more advanced [
Older patients with colon cancer are at a lower risk of having positive lymph nodes at the time of diagnosis [
Our patient had preeclampsia, which led to what was believed to be early manifestations of the HELLP syndrome. Preeclampsia is a pregnancy-related disorder associated with increased blood pressure and proteinuria, defined as a protein/creatinine ratio of >0.3 [
The incidence of primary colon cancer (46.9 per 100,000 men and 35.6 per 100,000 women, as estimated between 2009 and 2013) has been decreasing at an accelerated rate since the mid-2000s because of the availability of improved methods of detection and removal of premalignant, colonic polyps [
Anemia, abdominal pain, constipation, nausea, and vomiting are all common signs and symptoms that pregnant patients experience throughout their pregnancy. Unfortunately, these are also common signs and symptoms of early colon cancer. A concurrent pregnancy adds to the difficulties of diagnosing CRC, as it imposes limitations with respect to use of diagnostic modalities such as CT scans and X-rays, which are contraindicated, especially during the first trimester, due to their teratogenic potential. While ultrasonography and magnetic resonance imaging (MRI) are feasible alternatives, their specificity is less than that of CT, and MRI may still present a risk to the developing fetus [
According to the American Cancer Society (ACS), people with an average risk of CRC should be screened starting from 45 years of age, unless they are positive for any of the risk factors enumerated earlier (e.g., African-American descent, family history, heritable syndromes, and inflammatory bowel disease), in which case regular screening should be initiated earlier [
Although invasive investigations are considered safe, there is still an inherent risk of complications that may occur due to factors including preceding bowel preparation, sedatives administered for the procedure, or the procedure itself. Colonoscopy requires prior bowel preparation and is associated with the highest rate of complications such as perforation and GI bleeding. However, it provides the benefit of being able to remove suspected, premalignant polyps during screening. The right colon is not evaluated in a sigmoidoscopy, which precludes discovery of possible cancerous tissue at that location. While this procedure also requires prior bowel preparation, unlike colonoscopy, it is associated with fewer complications and may even be performed without sedation. CT colonography is a relatively new modality that necessitates performing colonoscopy subsequently, for the removal or biopsy of any suspicious lesions detected during the former test. It is a challenging modality to use in older adults because it requires adequate insufflation. However, patients are not required to be sedated, and its results, if negative (absence of suspicious colonic lesions), can help reassure patients without exposing them to the risk of an invasive diagnostic procedure [
Unlike invasive procedures, noninvasive investigations are considered as safe, initial tests for detection of CRC. The fecal immunochemical test is more specific and sensitive than the fecal occult blood test. Stool DNA testing has the highest sensitivity and improved specificity, as compared to that of other noninvasive procedures. Negative results of noninvasive tests can be used to reassure patients, without subjecting them to any invasive procedures. However, in the event of a positive result (true/false positive), the patient will have to be investigated further using an invasive procedure, usually a colonoscopy [
Our patient did not meet the standards of screening criteria for CRC with respect to factors including age, risk factors, and race. Her symptoms were subtle and could have been caused by the concurrent pregnancy. Considering solely HELLP syndrome as responsible for this patient’s elevated liver enzymes (which occurred secondary to liver metastasis) may have delayed the diagnosis even further. Atypical and incomplete presentation of suspected HELLP syndrome clued us to the possibility of occurrence of additional, unusual liver pathology, which the CT scan revealed to be the presence of metastasis.
In conclusion, colon cancer in a patient without family history of the condition (3%) and especially during pregnancy (0.002%) is rare [
The authors declare that there is no conflict of interest regarding the publication of this article.
We would like to acknowledge the contribution of Dr. Wilson J. Alan, M.D., who cared for the patient from a surgical standpoint.