Colorectal cancer in pregnancy: a rapid progressive disease

C olorectal cancer during pregnancy is uncommon and most patients present in late pregnancy. This report describes unusual presentations of colorectal cancer in relation to pregnancy in three patients. The first patient is a 30-year-old primipara that developed lower abdominal pain and constipation two weeks after an emergency cesarean section. She had no change in bowel habit, rectal bleeding, or weight loss. Within two weeks after delivery she developed progressive massive ascitis. She was found to have a hard mass in the rectum. Colonoscopy and biopsy was diagnostic of adenocarcinoma of the rectum. Patient died three days later from respiratory difficulty. The second patient is a 41-year-old grandmultipara who was noticed to have developed progressive ascitis in the last trimester of pregnancy. She had no associated constipation, rectal bleeding, or weight loss. Ultrasound revealed normal singleton intrauterine pregnancy and normal ovaries, liver, kidneys, spleen, and pancreas. She had spontaneous vaginal delivery at term and her ascitis worsened within one week. CT scan revealed tumor growth in the sigmoid colon which was surgically removed with eventual histopathologic diagnosis of adenocarcinoma of the sigmoid colon. The patient was treated with standard chemotherapy with good response. She was however lost to follow up after a year. The third patient is a 25-year-old multipara who had a spontaneous vaginal delivery of twins six weeks before presentation. She experienced a sharp vaginal pain during the first sexual intercourse after delivery. This was immediately associated with vaginal bleeding and within a week the vaginal bleeding was malodorous and mixed with fecal matter. She had developed a high rectovaginal fistula with necrotic edges. She had no constipation, rectal bleeding, or weight loss. Examination under anesthesia and biopsy of the fistula edges revealed an adenocarcinoma of the rectum. This patient unfortunately absconded when her disease condition and the need for surgery were explained to her. Colorectal cancer during pregnancy usually presents in the late stage of the pregnancy (1 3). This is typically exemplified in these three patients. Delayed diagnosis is attributed to confusion usually caused by the common lower gastrointestinal symptoms associated with pregnancy (1, 3). However, the occurrence of this condition in these three patients without preceding symptoms before and during the early part of pregnancy and the rapidity at which their symptoms developed and worsened suggest an aggressive disease process. This raises the question of whether this sudden onset of symptoms and the rapid worsening of the patient’s condition is due to the pregnancy itself. This association, though rare, is a real problem with regards to management as the diagnosis and the treatment are often delayed (3). Most patients present in late pregnancy, and the tumor is usually localized to the rectum (up to 85% of cases). However, tumors in transverse and rectosigmoid colon had been reported (1, 2, 4). Two of our patients had rectal cancer while the third had that of the sigmoid colon. The development of acute symptoms and rapidly progressive massive ascitis in two of our patients in the absence of obvious intra-abdominal macroscopic metastases and the symptoms of post-coital injury in the third patient are unusual presentations of this condition. These cases illustrate the fact that colorectal cancer in pregnancy could occur and progress rapidly without the usual preceding symptoms; therefore vigilance is needed to detect these unusual presentations. Post-coital laceration may be a sign of rectal carcinoma and therefore patients presenting with this problem need meticulous evaluation to rule out carcinoma of the rectum.