Pancreatic neoplasms in pregnancy: diagnosis, complications, and management

Abstract

Background: Neoplasms of the pancreas during pregnancy are rare, with less than 25 cases of benign and malignant tumors reported in the literature.

Methods: We present three unique cases of pancreatic tumors occurring during pregnancy--one mucinous cystic neoplasm and two adenocarcinomas. We review the literature regarding pancreatic neoplasms during pregnancy and discuss the diagnosis, complications, and management of these tumors.

Results: Magnetic resonance imaging and ultrasound are the imaging modalities of choice in pregnancy. In patients with benign or premalignant tumors, surgical resection may be postponed until the second trimester. In symptomatic patients, or if there is a concern for intrauterine growth restriction, urgent surgical intervention should be performed. With malignant tumors, the benefit of delaying surgery must be balanced with the risk of maternal disease progression. Termination of the pregnancy should be discussed when a malignant tumor is diagnosed during the first trimester. Pancreatic tumors diagnosed during the third trimester may be resected after delivery. If malignant, early delivery of the fetus and subsequent maternal operation can be considered at appropriate fetal maturity.

Conclusion: When these tumors occur during pregnancy, they present a diagnostic and treatment dilemma, with variation in treatment based on gestational age and patient preference.

Figure 1

Figure 1a. T2-weighted coronal MRI of a large pancreatic mucinous cystic neoplasm with adjacent liver, gallbladder, and compressed spleen. Figure 1b. T2-weighted axial MRI of a mature ovarian teratoma.

Figure 2

Figure 2a. Preoperative photograph of a 21-year-old patient at 20 weeks gestation with a large pancreatic mucinous cystic neoplasm. Figure 2b. A large mucinous cystic neoplasm was noted to originate from the body of the pancreas. Figure 2c. A mature ovarian cystic teratoma was simultaneously resected.

Figure 3

Postpartum CT scan showing several large liver masses, later found to be metastatic adenocarcinoma of the pancreas.

Figure 4

Figure 4a. ERCP demonstrating a common bile duct stricture with proximal ductal dilatation. Figure 4b. Endoscopic ultrasound revealing a 3.5 × 4.2 cm heterogeneous, hypoechoic mass.

Figure 5

Decision-making flowchart for a pancreatic mass diagnosed in pregnancy. Ultimate choices will be based on maternal and family preferences and should be discussed extensively with the patient.