Placental metastases from pancreatic adenocarcinoma in pregnancy

Abstract

A 37-year-old Chinese lady, who was in her fourth pregnancy, experienced intermittent epigastric pain and underwent an upper abdominal ultrasound scan at 22 weeks gestation. The scan revealed a 5×4 cm mass over the pancreatic head with multiple hepatic nodules, which was confirmed on magnetic resonance retrograde cholangiopancreatography. Laboratory tests showed obstructive jaundice and coagulopathy. Ultrasound-guided liver biopsy confirmed metastatic poorly differentiated adenocarcinoma, consistent with a pancreatic primary. Immunoperoxidase staining with chromogranin was negative, excluding the possibility of a carcinoid tumor. Extensive multidisciplinary discussions were carried out involving the obstetricians, surgeons, oncologists, radiologists, and pathologists. The patient and her family were counseled regarding the non-resectability of the tumor and the grave prognosis. They were offered the options of continuing with the pregnancy till 30–32 weeks with palliative care to the mother, versus the option of termination of pregnancy followed possibly by multi-agent chemotherapy. After considerable deliberation, the couple decided for termination of pregnancy, and she underwent the procedure with vaginal misoprostol at 24 weeks gestation. Histology of the placenta showed scattered islands of metastatic poorly differentiated adenocarcinoma seen within the maternal sinuses. Most of them appeared to be freely floating in the intervillous spaces, with the occasional clusters adherent to the surface of an adjacent chorionic villus (Figure 1). Immuno-histochemical studies for estrogen and progesterone receptors were negative. The patient subsequently received gemcitabine but had deteriorating hepatic and renal function as well as sepsis. She passed away 4 weeks from the time of the diagnosis. Placenta showing islands of poorly differentiated adenocarcinoma lying within the matemal sinus (H&E, magnification×150). Epigastric pain during pregnancy is commonly due to reflux, secondary to esophageal sphincter relaxation. This case illustrates that early diagnosis of a rare condition complicating pregnancy requires a high index of suspicion. As endoscopic retrograde cholangiopancreatography may be associated with radiation exposure to the fetus, the authors felt that magnetic resonance retrograde cholangiopancreatography and ultrasound-guided liver biopsy were more appropriate for making a diagnosis. Parental wishes, tumor stage, and gestational age are the important factors in this management dilemma. In early-stage disease, termination of pregnancy is an important option. For late-stage disease, termination of pregnancy is unlikely to improve maternal prognosis and pregnancy could be continued until fetal maturity is achieved. However, with termination of pregnancy, more palliative treatment such as stronger analgesia and chemotherapy could be considered to improve the mother's quality of life, without due consideration for the fetus. Whether the relatively immunocompromised state of pregnancy leads to more rapid progression of malignancy deserves more research. Pancreatic carcinoma could be estrogen or progesterone dependent 1, raising the question of whether termination of pregnancy could retard disease progression. This issue is not as crucial in our case due to her advanced disease. Prior to this case, 68 cases of maternal malignancy with metastases to products of conception have been reported 2, 3. Fourteen were metastases to the fetus and 54 were metastases to the placenta. There were only two prior cases of pancreatic adenocarcinoma with metastasis to the products of conception 4, 5. Our case is the third documented case. It was reported that the prognosis was ominous for mothers showing metastatic disease to the products of conception, with 93% dying of their disease shortly after delivery 3. This proved to be the case for our patient. In conclusion, a high index of suspicion is required to diagnose malignant conditions during pregnancy, and the management of malignant diseases in these women should be individualized.