Stage IV Pancreatic Adenocarcinoma in Pregnancy

To editor, Pancreatic cancer is the third leading cause of cancer-related death in the United States. However, it is rarely diagnosed during pregnancy, as the median age of onset is around 70 years. Fewer than 3% of cases occur in individuals under 45 years of age.1 Genetic mutations, such as BReast CAncer gene 1 (BRCA1) and BReast CAncer gene 2 (BRCA2), increase the risk of pancreatic cancer, with BRCA2 mutations associated with a 5%–10% lifetime risk.2 The disease is often asymptomatic until advanced stages. When present, symptoms—such as nausea, vomiting, abdominal pain, and weight loss—often overlap with common complaints during pregnancy. Diagnostic imaging is further complicated by concerns about fetal radiation exposure. To date, only around 10 cases of metastatic pancreatic adenocarcinoma during pregnancy have been reported.3–6 Managing such cases requires careful balancing of maternal and fetal risks. This report presents a case of stage IV pancreatic cancer diagnosed during pregnancy, emphasizing diagnostic, therapeutic, and delivery considerations. Written informed consent was obtained from the patient. A 32-year-old G1P0 woman with a BRCA2-positive status and an in vitro fertilization pregnancy presented at 21 weeks of gestation with severe epigastric pain. She had a history of cholecystectomy and was initially diagnosed with suspected gastritis. Preeclampsia was ruled out. Abdominal ultrasound revealed a dilated bile duct, suggesting sphincter of Oddi dysfunction, and she received conservative management. By 25 weeks, her abdominal pain worsened, and she had lost 30 pounds. Repeat ultrasound showed hepatomegaly, echogenic liver, and a right pleural effusion. Chart review revealed a prior computed tomography (CT) scan with findings suggestive of pancreatic steatosis. Endoscopic ultrasound identified a 42×33 mm hypoechoic mass in the pancreas. Fine-needle aspiration confirmed pancreatic adenocarcinoma. Tumor markers were elevated: cancer antigen (CA) 19-9 at 8229 U/mL, carcinoembryonic antigen at 165.4 ng/mL, and CA-125 at 241 U/mL. The patient was referred to Henry Ford Hospital for multidisciplinary management. Thoracentesis removed 1550 mL of pleural fluid, and cytology confirmed metastatic adenocarcinoma. Imaging revealed metastases to the liver, lungs, spleen, and omentum, confirming stage IV disease. She began chemotherapy with gemcitabine and cisplatin. At 32 weeks, labor was induced to optimize maternal treatment, balancing the risks of prematurity with the need for timely systemic therapy. Pain control was a significant challenge. After multiple trials, pain was managed with sustained-release morphine sulfate (MS Contin). Gastroenterology recommended an endoscopic-guided celiac plexus block—an uncommon procedure during pregnancy due to fetal safety concerns. After extensive counseling and literature review, the patient proceeded with the block, which resulted in moderate pain relief and no fetal complications.7–9 Psychiatric support was initiated for anxiety and depression, and the patient received an selective serotonin reuptake inhibitor alongside palliative care consultations for emotional support and advanced care planning. Following a 26-day hospital stay, she was discharged home with improved pain control and no oxygen requirement. She completed two chemotherapy cycles before delivery. At 32 weeks and 6 days, a cesarean section was performed after failed labor induction. The infant, weighing 1585 g, required 17 days in the neonatal intensive care unit (NICU) for suspected sepsis, intermittent morphine withdrawal, and phototherapy. Postpartum, chemotherapy transitioned to modified FOLFIRINOX (5-FU, irinotecan, oxaliplatin). The patient tolerated the regimen well, and follow-up imaging showed disease response. After eight cycles, she enrolled in a phase II trial involving olaparib and pembrolizumab. At 15-month follow-up, her disease remained under control.9 This case highlights the unique challenges of diagnosing and managing pancreatic adenocarcinoma during pregnancy—an exceedingly rare condition with limited literature. Symptom overlap with pregnancy-related discomfort often delays diagnosis. In this case, fragmented medical records hindered recognition of prior CT findings and her BRCA2-positive status. This underscores the need for comprehensive history-taking, cross-institutional collaboration, and improved access to unified medical records. Optimal care requires coordinated involvement from obstetrics, maternal-fetal medicine, oncology, neonatology, palliative care, and psychiatry. Shared decision-making is critical to balance maternal treatment urgency with fetal development considerations. Pain control is central to maintaining quality of life. In this case, the endoscopic celiac plexus block—although rarely used in pregnancy—offered an effective, opioid-sparing option, demonstrating the potential for personalized and evidence-informed care strategies.7–9 Chemotherapy in the second and third trimesters is increasingly accepted, especially with platinum-based regimens such as gemcitabine and cisplatin. The postpartum transition to intensified treatment (FOLFIRINOX) followed standard oncologic care principles while ensuring maternal safety.7–9 Delivery at 32 weeks balanced the need for maternal therapy and neonatal maturity. NICU care ensured favorable neonatal outcomes, highlighting the importance of perinatal planning. Lessons learned are maintaining a high index of suspicion for malignancy in pregnant women with persistent, unexplained symptom, early engagement of a multidisciplinary team is essential for optimal outcomes, and Novel interventions (e.g., celiac plexus block) and postpartum therapeutic flexibility can improve survival and quality of life. Given the rarity of pancreatic cancer in pregnancy, data must be gathered through multicenter registries and case series. Further research is needed on chemotherapy safety, novel pain management, and targeted therapies in the perinatal setting. This case underscores the importance of early recognition, multidisciplinary collaboration, and individualized treatment in managing pancreatic adenocarcinoma during pregnancy. Ongoing research and improved clinical awareness are key to enhancing outcomes for both mother and child.