THE KURUMEMEDICAL JOURNAL VoL44, p. 179-183, 1997 ORIGINAL ARTICLE

Gastric Ca4ncer during Pregnancy

ISSEI KODAMA, JINRYO TAKEDA*, KIKUO KOUFUJI, SHOJIRO YANO, MAT HANZAWA AND KAZUO SHIROUZU Departments of Gastroenterology and Surgery, School of Medicine, Kurume 830,

Received for publication May 15, 1997

Summary: During the 27 years between 1966 to 1993, a total of 3,256 patients with gastric cancer were admitted to our institute. Among these patients, 3 (0.1%) cases of gastric cancer were associated with pregnancy. One cancer stage IVb patient died of peritoneal metastasis without any operation. Another stage Wb patient died of peritoneal metastasis 12 months after palliative gastrectomy. And the other stage IIIb patient is well, and the 8 years old child is also well, after synchronous extended total gastrectomy with cesarean section.

Key words gastric cancer, pregnancy, delivery, peritoneal metastasis , prognosis

Introduction Patients with gastric cancer discovered after delivery were excluded from the It has been reported that gastric present study. cancer diagnosed during pregnancy is a The cancer stage, regional lym- rare event, frequently at a very advanced phadenectomy, macroscopic and micro- stage of cancer, and usually with a poor scopic cancer type, cancer location, prognosis. To improve the diagnostic classification of the depth of invasion, and therapeutic management of these operative method and cancer stage were problematic gastric cancer patients, we determined according to the Guidelines have retrospectively investigated three of the Japanese Research Society for gastric cancer patients during preg- Gastric Cancer (1995). nancy.

Results Patients and Methods The family history of malignancy, During the 27 years between 1966 chief complaint, month of pregnancy at and 1993, a total of 3,256 patients with the time of gastric cancer diagnosis, gastric cancer were admitted for surgery obstetric and surgical managements, to the First Department of Surgery, cancer location, type of gastrectomy, Kurume University Hospital. Among Borrmann type of gastric cancer by these patients, 3 (o.1%) cases of gastric endoscopy, endoscopic biopsy and/or cancer were associated with pregnancy. radiographic findings, pathology, pres-

179 180 KODAMA ET AL. ence or absence of peritoneal dissemi- 14th postoperative day, postoperative nation (P) and hepatic metastasis (H), chemotherapy was started with a peroral Virchow's node metastasis (distant administration of 300 mg/day 5-fluo- organ metastasis other than peritoneal rouracil. The patient was discharged or liver metastases, or metastasis to from hospital on the 27th postoperative lymph nodes beyond Group 4 is defined day. The patient had a good quality of as M1) and cancer stage of the patients life at home, but died of carcinomatous are summarized in Table 1. peritonitis 12 months after the gastrec- Case 1 underwent induced abortion tomy. and palliative distal gastrectomy to Case 2 underwent a chemically- prevent pylorus stenosis, and numerous induced abortion, with no operation for metastases to the distant peritoneum the gastric cancer due to the presence of (P3) were discovered during the P3 with ascites, massive invasion of the operation. The resected specimen showed adjacent organs with esophageal infiltra- Borrmann type IV gastric cancer with tion, and the presence of large Virchow's massive serosal invasion. The postopera- node metastasis in the left cervical region. tive course was uneventful and the Case 3 underwent both obstetric and adjuvant chemotherapy included 20 mg surgical treatment synchronously. The iv Mitomycin C during gastrectomy and baby was delivered at 28 weeks' gesta- 10 mg on the first operative day. On the tion by cesarean section and is doing

TABLE 1. Summary of 3 gastric cancer patients during pregnancy

P: peritoneal metastasis, H: hepatic metastasis, por2: poorly differentiated adenocarcinoma (non-solid type), sig: signet-ring cell carcinoma GASTRIC CANCER IN PREGNANCY 181

fine to date. In the same operation the cancer is often delayed by the patient or mother underwent hysterectomy and doctor (Yakushiji et al. 1987; La Vecchia bilateral ovariectomy because of high risk et al. 1994). The symptoms of gastric of occult Kruckenberg metastasis and to cancer such as nausea, vomiting and prevent hemorrhagic complications follow- abdominal pain are similar to those ing cesarean section. Both parents had associated with pregnancy. Careful previously decided not to have any discriminatory examination for potential additional baby, in any case. For the gastric cancer by radiography is often gastric cancer, the patient underwent limited by the doctor to avoid any simultaneous extended radical total gas- unnecessary risk to the fetus during trectomy, with combined distal pancre- pregnancy. atico-splenectomy, D4 lymphadenec- The characteristics of gastric cancer tomy including the para-aortic nodes, diagnosed during pregnancy or within 2 and retrocolic Roux-en-Y reconstruction, years after delivery are a high incidence without any postoperative complica- of poorly differentiated type with scir- tions. A peroral administration of 300 rhus growth pattern, a high incidence of mg/day 5-fluorouracil was continued 3 far-advanced cancer, a significantly higher years. The mother and child are well at 8 incidence of peritoneal dissemination, years after the operation. and a mean interval between conception and diagnosis of gastric cancer of 14.6 months (Maeta et al. 1995). The pregnan- Discussion cy-associated cases also had a higher incidence of Borrmann type IV gastric Diagnosis of gastric cancer during cancer than non-pregnant young females pregnancy is quite rare. The incidence with gastric cancer. Furukawa et al. rate of gastric cancer during pregnancy (1994) also reported that the diffuse among all gastric cancer patients was microscopic type of gastric carcinoma only 0.17% (4/2325) as reported by Maeta (Lauren, 1965) represented 75% (15/20) et al. (1995), and was 0.1% in the present of the cases of gastric cancer diagnosed study. within 2 years after delivery, with a low This very low incidence can be incidence rate of early cancer, and that attributed to the age factor. The inci- the pregnancy-associated cancer was dence rate of gastric cancer among more aggressive compared to that in female patients less than 30 years old is other young female patients with or 1.9%, as reported by Miura et al. (1986). without children, or in young male Gastric cancer in such young patients is patients. frequently very advanced and usually There have been only a few reports has a poor prognosis. Moreover, the of early gastric cancer during pregnancy hormonal environment of pregnancy (Miura et al. 1986; Hirabayashi et al. accelerates the already rapid growth of 1987). These cancers were diagnosed by the cancer, the symptoms of which are endoscopy or endoscopic biopsy, and often masked by changes associated were associated with gastric cancer with pregnancy, and examination for related symptoms of epigastric pain and 182 KODAMA ET AL.

hematoemesis. gastrectomy after 28 weeks' gestation. The prognosis of gastric cancer Prior to 16 weeks' gestation, radical associated with pregnancy has been gastrectomy should be selected after an reported to be very poor, because of the induced abortion. For surgical and high incidence of advanced stage of obstetric management of gastric cancer cancer of diffuse type Borrmann IV during pregnancy, the informed consent cancer, with a high incidence of from patient and family is important. peritoneal metastasis and of recurrence. Endoscopy during pregnancy would Ueo et al. (1991) reviewed 61 cases of improve the prospective survival rate. gastric cancer associated with pregnancy including 27 cases of cancer diagnosed within two years after delivery. Fifty- References nine (97%) of the 61 cases were of advanced stage cancer with an overall Furukawa H, Iwanaga T, M, Imaoka resectability rate of only 48%. The S, Ishikawa O et al. Gastric cancer in young incidence rate of hospital mortality was adults: a growth accelerating effect of 59% overall; 93% among the inoperable pregnancy and delivery. J Surg Oncol 1994; 55:3-6. cases, 57% among the operated cases, Hirabayashi M, Ueo H, Okudaira Y, Matsumata and 23% after gastrectomy. These inci- T, Hanawa S et al. Early gastric cancer and a dences were higher for a cancer occur- concomitant pregnancy. Am Surg 1987; 53: ring during gestation than after delivery. 730-732. For gastric cancer occurring during Japanese Research Society for Gastric Cancer. gestation, the 3-year survival rate was Japanese Classification of Gastric Carcino- 21%, and the 4-year survival rate was 5%, ma, ed. Nishi M, Omori Y and Miwa K, after gastrectomy. Mackey et al. (1996) Kanehara, , First English edition, 1995. reported one patient surviving 36 Lauren P. The two histological main types of months after the initial diagnosis of gastric carcinoma: diffuse and so-called intestinal type carcinoma. Acta Pathol metastatic carcinoma from the stomach Microbiol Scand 1965; 64:31-49. to the ovaries bilaterally following pal- La Vecchia C, D'avanzo B, Franceschi S, Negni liative gastrectomy and oophorectomy. E, Parazzini F et al. Menstrual and repro- Our case 3 had stage IIIb advanced ductive factors and gastric-cancer risk in gastric cancer. Following combined women. Int J Cancer 1994; 59:761-764. cesarean section and extended radical Mackey JR, Hugh J, and Smylie M. Kruckenberg gastrectomy after hysterectomy and tumor complicated by pregnancy. Gynecol oophorectomies, she is now well. Oncol 1996; 61:153-155. Gastric cancer during pregnancy is Maeta M, Yamashiro H, Oka A, Tsujitani S, Ikeguchi M et al. Gastric cancer in the young, usually advanced and if it is considered with special reference to 14 pregnancy- to be curable by resection, immediate associated cases: analysis on 2,325 consecu- radical gastrectomy is recommended tive cases of gastric cancer. J Surg Oncol despite the risk to the fetus. If a 1995; 58:191-195. hemorrhagic tendency is suspected Miura T, Ishii T, Shimoyama T, Hirano T, during pregnancy, then cesarean section Nakagoe T et al. Adenocarcinoma of the should be combined with curative stomach associated with pregnancy. Acta GASTRIC CANCER IN PREGNANCY 183

Med 1986; 31:276-287. Yakushiji M, Tazaki T, Nishimura H, and Kato T'. Ueo H, Matsuoka H, Tamura S, Sato K, Kruckenberg tumors of the ovary: a d in- T'sunematsu Y et al. Prognosis in gastric icopathological analysis of 112 cases. Acta cancer associated with pregnancy. World J obstet Gynecol J 1987; 39:479-485. Surg 1991; 15:293-298.