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Postpartum CRC Case Study
Q&A From a New Mother With Metastatic Colon Cancer: My Management of the Case and Follow-up

Released: January 11, 2018

Expiration: January 10, 2019

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A month after delivery of a healthy baby girl, a 30-year-old woman presented to an outside hospital due to upper abdominal pain, weight loss, and rectal bleeding. Other than the recent pregnancy, she has no pertinent past medical history or family history. She had a fullness in the midepigastrium. Laboratory analysis revealed hemoglobin 12.5 g/dL plus total bilirubin 2.6 mg/dL; other laboratory values were within normal limits. PET/CT revealed 4 lesions virtually replacing the left lobe of the liver, but no lesions were seen in the right lobe. The PET showed spotty avidity in the sigmoid colon and the left lobe of the liver. The CT suggested narrowing of the sigmoid colon. Colonoscopy revealed a nonobstructing, nonbleeding mass in the sigmoid colon—the biopsy was consistent with mucinous adenocarcinoma.

The patient now presents for a second opinion after numerous questions were raised. In particular, the patient and her husband were concerned that the cancer may have been transmitted via the placenta to their daughter. What did I think? More later.

Is Cure Possible?
The PET and CT scans were done without IV contrast and mucinous metastases are not reliably PET avid. So, it is not possible to determine whether a cure is feasible because the imaging is not complete.

Can She Be Treated With Immunotherapy Instead of Chemotherapy?
We would not typically offer immune checkpoint inhibitors as first-line treatment for colorectal cancer, but this depends on knowing whether the tumor has microsatellite instability or mismatch repair deficiency, as well as other biomarkers. A call to the pathologist reveals that there is not enough tissue left for proper analysis.

Is the Total Bilirubin Level an Indicator That She Has Advancing Liver Disease?
Not necessarily. Other liver enzymes are within normal limits. Review of her medical records from before and during the pregnancy reveals total bilirubin ranging from 0.8-2.9 mg/dL during the past year. The current scan shows no biliary ductal dilatation.

Can the Patient Receive Immediate Surgery?
Despite the patient’s request for immediate surgery, she has an asymptomatic primary tumor and nontrivial, albeit resectable, liver metastases. Immediate surgery is not recommended.

Which Chemotherapy Is Optimal? Should She Also Receive a Biologic Agent?
The patient states that she prefers to have a port placed because “they can never get blood from my veins.”

Recommendation: Repeat the CT with contrast to better determine the spread of disease, schedule a repeat sigmoidoscopy to acquire an ample tumor specimen for molecular characterization, and ask the lab to fractionate the bilirubin.

Treatment
A CT with contrast 2 days later showed no findings beyond what was seen on the original PET/CT. Because the original tumor specimen was deemed to have inadequate tumor cells, a sigmoidoscopy was done and the biopsy sent for molecular characterization. The direct bilirubin was 0.4 mg/dL and indirect bilirubin was 2.5 mg dL. Choice of initial therapy was made based on the information available at the time.

For this patient, I recommended FOLFOX without a biologic agent. Irinotecan is not favored in a patient with Gilbert syndrome, and regardless of RAS status, the use of an EGFR-targeted antibody as part of neoadjuvant treatment prior to liver metastasis resection leads to a poorer outcome in such patients. I offer bevacizumab but explain the risks and relative benefits in detail, particularly the danger of a stroke in the postpartum period.

A port was placed and mFOLFOX6 was initiated. Three days later, the molecular features were as follows: KRAS codon 12 mutation, microsatellite stable, and HER2 negative. In addition, the patient was able to take advantage of open enrollment and changed insurance to gain routine access to our hospital.

We stayed the course. After the fourth cycle, imaging revealed a 40% reduction in tumor size with no new lesions. The sigmoid colon now appeared normal. The patient was referred to our surgical colleagues and underwent a left hepatectomy and sigmoid colon cancer resection in the same operation. The pathologist described marked tumor necrosis in all sites of disease, with 14 lymph nodes negative for metastatic disease. The patient subsequently received 4 additional cycles of FOLFOX before developing neuropathy, at which point chemotherapy was discontinued.

Follow-up
A repeat scan 1 year from diagnosis shows the patient to be without evidence of disease.

As for the baby, she is meeting all landmarks and appears to be developing normally. In the interest of completeness, we offer to take a blood specimen from the baby and analyze it for circulating cell-free tumor DNA. This may clarify whether the baby was inoculated with cancer cells during her pregnancy; the absence of cell-free tumor DNA would not be a guarantee, however, due to a lack of data.

We recommend against the test because we would not know what to do with the results. For the moment, the parents agree.

For evidence-based expert guidance on selecting therapy in your patients with metastatic colorectal cancer based on multiple patient and tumor characteristics, please review Clinical Care Options’ Interactive Decision Support Tool.

Your Thoughts?
How would you treat a new mother with metastatic colon cancer? Share your thoughts in the comment box below.

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Would you order rebiopsy on a patient with newly diagnosed metastatic colorectal cancer (with insufficient tissue from original biopsy) in order to obtain molecular characterization to guide your therapy selection?
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