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We report a rare case of pregnancy with concomitant pancreatic cancer. At 28 weeks' gestation, the patient was diagnosed with a large tumoral mass in the head of the pancreas. She had a cesarean section at 32 weeks' gestation due to premature labor and underwent surgery for pancreatic cancer in her third month postpartum.
Pancreatic cancer is the fourth leading cancer in all age groups and for both sexes, with an incidence of 11% in women and 14% in men and a 5-year survival rate of 8% (1). Its incidence peaks beyond the fifth decade (1). Cases of pancreatic cancer during pregnancy have been very rarely reported (2–8). We report a case of pregnancy with concomitant pancreatic cancer.
A 36-year-old multiparous white obese pregnant woman was admitted to the emergency department with complaints of recurrent severe abdominal pain radiating to the back, jaundice, nausea, and vomiting. She was 28 weeks pregnant according to her last menstruation date and fetal ultrasonographic evaluation. She had a history of two vaginal healthy term deliveries. Her body mass index was 30.6 kg/m2. She was receiving subcutaneous insulin treatment for diabetes mellitus for 1 year. She was an active smoker for the last 5 years, smoking half to one pack of cigarettes per day.
Initial laboratory values indicated elevated liver function tests: aspartate aminotransferase, 66 IU/L (normal < 45); alanine aminotransferase, 86 IU/L (normal < 45); total bilirubin, 1.5 g/dL (normal < 1.2); direct bilirubin, 0.7 g/dL (normal < 0.4); alkaline phosphatase, 416 U/L (normal < 120); and gamma-glutamyl transpeptidase, 286 U/L (normal < 45). Her amylase level (23 U/L, normal < 85) and lipase level (142 U/L, normal <160) were within normal limits. Abdominal ultrasonography revealed dilation in the intrahepatic bile ducts and hydropic gallbladder. Tumor markers were within normal limits, except carbohydrate antigen 19-9 (232 U/mL, normal < 37).
Advanced radiological studies, including magnetic resonance imaging and magnetic resonance cholangiopancreatography, revealed a pancreatic multilobulated mass (60 × 70 mm) mostly located in the head and extending to the tail of the pancreas, causing compression of the common bile duct, dilation in the intrahepatic bile ducts, and hydropic gallbladder (Figure 1). A gastroscopy was performed, demonstrating a fragile ulcerated polypoid mass constricting lumen in the ampulla. Histopathological examination was reported as cytokeratin-7 positive adenocarcinoma. Consultants from general surgery and medical oncology were brought in. Due to the patient's preference to avoid oncological intervention before giving birth to a term baby, she was scheduled for tumoral resection and adjuvant chemotherapy after birth.
At the 30th gestational week, a threat of premature labor was managed with low-dose intravenous ritodrine. She was given betamethasone treatment for 2 weeks to promote fetal lung maturation. At the 32nd gestational week, cesarean section was performed because of threat of premature labor. However, postoperatively the patient had an attack of thrombophlebitis in the right leg and was started on low-molecular-weight heparin together with empirical antibiotic treatment. General surgeons performed a Whipple operation 3 months after delivery. Local invasive pancreas adenocarcinoma was diagnosed, and the patient was referred to medical oncology.
Since pancreas carcinoma usually occurs at an older age, it has rarely been reported during pregnancy. Previous reported cases (1–8) are summarized in Table 1. The patients generally went to the emergency room due to complaints including abdominal pain, acute abdomen, acute back pain, acute jaundice, scleral icterus, pancreatitis, and a threat of premature labor (2–8). Pancreatic cancer was generally diagnosed based on radiological studies (2, 4–6, 8) or intraoperatively (3, 7) when emergent laparotomy and/or cesarean section were performed. At the time of diagnosis of pancreatic cancer in pregnant women, cancer was mainly locally invasive (2, 3, 7, 8) or metastatic (4–6). Adenocarcinoma, the most common histological subtype of pancreatic cancer, was associated with the highest mortality in pregnancy-associated cases (2–6). Other rare subtypes like mucinous cystic neoplasm or intraductal papillary-mucinous tumor had better survival rates after treatment (7, 8). Serum carbohydrate antigen 19-9 has low sensitivity for discriminating benign from malignant pancreatic disease but is generally high when the mass is large (2, 7–9). Nevertheless, some cases showed relatively low levels of serum carbohydrate antigen 19-9, as in our case (5).
Our case involved an obese person, and obesity has been implicated in pancreatic cancer (10, 11). In addition, higher levels of circulating C-peptide/insulin and glycemia are risk factors for pancreatic cancer and were present in our case (12). Approximately 50% of patients with pancreatic cancer have diagnosed diabetes mellitus (13). The median duration between a diagnosis of diabetes mellitus and subsequent pancreatic cancer is 6.5 months (13). The risk of pancreatic cancer is highest among those with recent-onset diabetes and/or those with recent initiation of insulin therapy, as occurred in our case (14).