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... 70 When discovered during pregnancy, most cancers arise from the rectum compared with the nonpregnant state when most cancers arise from the extra pelvic colon. 76 Usually colon cancer is detected in its advanced stages secondary to late diagnosis during pregnancy. Bernstein et al reviewed 41 patients with colorectal cancer during pregnancy and observed that all patients had stage II or greater disease. ...
... Unfortunately, CEA levels tend to be normal or slightly elevated during pregnancy and are not considered a useful screening tool with a low sensitivity and specificity. 76 Abdominal CT imaging also assists in staging of colorectal cancer, but is relatively contraindicated in pregnancy secondary to the fetal risk with radiation exposure. 70,76 Abdominal ultrasonography is a reasonable alternative to CT especially for detection of hepatic metastases with a sensitivity of 75%. ...
... 76 Abdominal CT imaging also assists in staging of colorectal cancer, but is relatively contraindicated in pregnancy secondary to the fetal risk with radiation exposure. 70,76 Abdominal ultrasonography is a reasonable alternative to CT especially for detection of hepatic metastases with a sensitivity of 75%. However, because of the gravid uterus, its role may be limited in evaluation of the pelvis. ...
Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.
... 12 Considering racial predisposition, Hispanic women were slightly less likely to develop CRC, in comparison with non-Hispanic white women. 8 Most of CRC in pregnancy is an aggressive mucinous subtype, 8 which have poorer prognosis, 17 but primary signetcell carcinoma (SRCC) of the colon and rectum also represents a form of adenocarcinoma of the large intestine. Although its rare incidence of about less than 0.1% of cases of CRC in pregnancy, patients with SRCC are younger. ...
... 6,21 Some investigators demonstrated that 20-54% of colon cancers have oestrogen receptors (Ers), whereas others have demonstrated progesterone receptors (PgRs), which may be stimulated by the oestrogen and progesterone produced during pregnancy. The role of these hormones in the aetiology and progression of CRC are limited and conflicting, 12 In fact, CRC pathogenesis and its relation to pregnancy is not well understood, 8,12,17 and studies show that parity is not positively neither negatively associated with CRC. 8 When discovered during pregnancy, two-thirds of CCR in pregnant women tend to involve the rectum and sigmoid colon, unlike the general population where two-thirds arise from the extra pelvic colon. 4,17 In fact, it is was reported that about 85% of CRC in pregnancy are below the peritoneal reflection. ...
... The role of these hormones in the aetiology and progression of CRC are limited and conflicting, 12 In fact, CRC pathogenesis and its relation to pregnancy is not well understood, 8,12,17 and studies show that parity is not positively neither negatively associated with CRC. 8 When discovered during pregnancy, two-thirds of CCR in pregnant women tend to involve the rectum and sigmoid colon, unlike the general population where two-thirds arise from the extra pelvic colon. 4,17 In fact, it is was reported that about 85% of CRC in pregnancy are below the peritoneal reflection. 1,5,12,16 ...
Colorectal cancer in pregnancy is a rare pathology with limited high-grade evidence available for guidance. The diagnosis of CRC in pregnant women is usually delayed, and once diagnosis is made, challenges exist as treatment options may be limited.
The study aims to highlight the importance of early investigation of symptomatic patients during pregnancy, as well as to update treatment and prognosis in CRC.
A literature search in PubMed database, including articles from 2006 to 2016 and cross-research articles with the initial research.
Pregnancy can limit and contraindicate the utilization of standard diagnostic and therapeutic tools, which in particular can hamper the liberal use of colonoscopy and CT. Physical evaluation and abdominal US are first recommended; besides, MRI or CT may be used, only in indicated cases. Surgery is the main stay of treatment but radiotherapy and chemotherapy have significant role in posterior management of tumour.
Many studies are needed in order to achieve development in CRC pathogenesis during pregnancy as well as in treatment outcomes. The potential curative treatment of the disease should be the main aim of treatment when considering CRC in pregnancy. However, it is crucial to adapt the treatment to each patient, taking into account conscious decision on pregnancy further management.
... Values above 10 mg/l should be investigated without delay. CEA levels are used for following up for recurrence of pregnant cancer patients . CT scan is the standard imaging technique in detecting locoregional and distant disease in CRC, but it is not recommended in pregnancy because of carcinogenic and teratogenic effects on fetus. ...
... CT scan is the standard imaging technique in detecting locoregional and distant disease in CRC, but it is not recommended in pregnancy because of carcinogenic and teratogenic effects on fetus. The MRI without the use of gadolinium seems to be safe in pregnancy and is preferred to CT for cancer staging in pregnancy . Colonoscopy is the most definitive diagnostic modality in diagnosing colorectal cancer but is avoided in pregnancy because of risk of uterine pressure, placental abruption, and intestinal perforation. ...
Globally, colorectal cancer is a substantial health burden. This case will discuss about challenges during management due to pregnancy. To the best of our knowledge, very few cases of this type have been reported in literature.
A 20 - year - old married, pregnant female, second gravid and para 1 presented during her 34th week of gestation, with complaints of something coming out of the anus, bleeding per rectum, abdominal distension and relative constipation for 8 months. CEA was normal. CT scan and MRI showed circumferential mural thickening of length 7.5cm involving anal canal and anorectal junction, associated with perilesional fat stranding. The Neoadjuvant chemoradiotherapy was advised after c section.
This case report highlights the fact that early detection and management of colorectal cancer during pregnancy can prevent morbidity and mortality.
... Although its incidence is rare, it is associated with serious consequences for both the mother and even the fetus . Its clinical manifestation, diagnosis, and treatment options seem a big challenge in front of treating physicians . In some cases, it is possible only to save one life between the mother and the fetus which demands a deep ethical consideration and also religious challenges. ...
The incidence of colorectal cancer (CRC) during pregnancy is so rare. Herein we present a case of colorectal cancer that was missed by pregnancy all over the pregnancy period. The patient was a 37-year-old woman (gravid 4, para 2) referred with the complaints of vaginal discharge and suspicious rupture of membrane (ROM). The patient was pale and the initial physical examination revealed dilation of two fingers, effacement about 30%. She underwent emergent cesarean section which showed adhesions surrounding the uterus, the bladder, and the abdominal wall. Forty days postoperatively, the patient presented with abdominal pain in the left upper quadrant (LUQ). Imaging confirmed a mass in LUQ. Partial colectomy of transverse colon (20 cm) was performed. Postoperative histopathologic study revealed a 7 ∗ 6 ∗ 5 cm mass in transverse colon compatible to stage IIa of the Duck class (T3, N0, Mx). Adjuvant chemotherapy was applied and the patient showed improvements during 7 months followup after surgery. Colorectal cancer in pregnancy is associated with diagnostic and therapeutic challenges which mostly lead to late diagnosis in advanced stages and poor prognosis. A targeted program to improve the general population knowledge and the establishment of a national consultant and screening program particularly for women with a planned pregnancy in the high risk group might be beneficial.
... En cuanto al tratamiento (9)(10)(11), en el primer trimestre es similar al de la paciente no gestante, la cirugía radical con frecuencia se asocia a aborto. Es posible extirpar las trompas, ovarios y útero según los deseos de la paciente y los hallazgos en el momento de la laparotomía. ...
El cáncer de colon durante la gestación es una patología poco frecuente, con una incidencia entre el 0,07 y el 0,1%. El diagnóstico precoz es complejo y el pronóstico suele ser malo por tratarse con frecuencia de procesos en estado avanzado. Presentamos el caso de una paciente de 38 años, diagnosticada de ade-nocarcinoma de colon transverso metastásico en la semana 31 de gestación. Realizamos una revisión en relación al diagnóstico y manejo de esta patología.
... constipation, change in bowel habits, nausea and vomiting), which can occur due to physiological changes during pregnancy, can create difficulties to establish the diagnosis.  However, there is a few epidemiological data for this rare condition. A study by the American Society of Colon and Rectal Surgeons investigating 41 cases revealed a mean age of 31 years 11 when diagnosis was obtained. ...
Colon cancer in pregnant women is rare and tends to produce unspecific symptoms until advanced stage. Therefore common manifestations during pregnancy must be properly evaluated to avoid delayed diagnosis.
Presentation of case
A 31-year-old pregnant woman presented with nausea, vomiting and obstipation. An obtained magnetic resonance imaging (MRI) showed distended colon and the consecutive colonoscopy with biopsies confirmed the diagnosis of stenosing carcinoma of the descending colon. Left sided hemicolectomy was performed 10 days after initial presentation. Tumor histology confirmed the diagnosis of adenocarcinoma of the descendo-sigmoidal junction. Adjuvant chemotherapy with 5-fluorouracil was started in the 29th gestational week. The patient had an uneventful delivery of a healthy baby in her 39th gestational week.
Colorectal carcinoma during pregnancy is a rare event and its diagnosis is often delayed because symptoms are unspecific until the disease is advanced. Although constipation in pregnancy is a common symptom differential diagnosis of a mechanical stenosis should always be contemplated, especially when conservative treatment of constipation fails. MRI is the imaging tool of choice as abdominal computed tomography (CT) is contraindicated in pregnancy. Endoscopic confirmation should be obtained to gain pathological diagnosis of colorectal carcinoma. Surgery is the gold standard of treatment. In relation to the stage of the disease chemotherapy is of great importance.
Obstructing colorectal cancer can be a rare reason for the common problem of constipation in pregnancy. Beside clinical examination, MRI scan and colonoscopy will reveal the tumor in most cases and should be followed by surgical treatment and chemotherapy according to the stage of disease.
... Colorectal cancer (CRC) during pregnancy is rare, with an incidence of 1 in 13,000 pregnancies [2,10,14]. Although infrequent, CRC cases during pregnancy have been reported in the past decade . With thetrendindelayedchild-bearing,theraresituationofCRCduring pregnancy will likely rise in incidence. ...
: Cancer diagnosed during pregnancy has increased because of delayed child-bearing and the known occurrence of age-dependent malignancies. Cases of colorectal cancer (CRC) in pregnancy have recently been reported. With the expected rise in CRC diagnosed in young adults coupled with the current trend of delayed child-bearing, CRC during pregnancy is likely to increase. Treating pregnant women with CRC by using antineoplastics presents a dilemma because there are many unknowns to guide treatment decisions. We review the issues regarding the use of 10 CRC-approved agents in pregnancy.
Implications for practice:
Colorectal cancer (CRC) in pregnancy is likely to become more common because of the current population trend in delayed child-bearing and the increase in CRC incidence expected among young adults. Practitioners should become familiar with the challenges associated with systemic treatment of a pregnant patient with CRC. This review addresses concerns surrounding the 10 systemic agents approved for CRC to help provide treatment guidance when such a case arises.
... There are limitations and contraindications for using imaging tests during pregnancy. Ultrasound, a safe images test, has limited accuracy in detecting colorectal cancer, and colonoscopy -which is the gold standard test for diagnosing colorectal cancer -can't be used in pregnancy because of its complications (11)(12)(13) . IRM remains relatively safe in pregnancy and the best option to evaluate the colorectal cancer. ...
The incidence of colorectal cancer during pregnancy is reduced, being estimated at approximately one in 1000 preganancies. Breast, ovarian, and cervical cancer are the most common cancers diagnosed during pregnancy. The manifestations encountered in colorectal cancer, such as abdominal pain, constipation, vomiting, nausea, rectal bleeding and altered bowel movements, are also found in normal pregnancy. In this paper, we present a case of colorectal cancer with hepatic metastasis diagnosed in a 36-year-old preganant woman (IIG, 1P), at 32 weeks of pregnancy.
... Cancer during pregnancy occurs in about one out of 1000 pregnancies , with hematologic and gynecologic malignancies being the most common forms . Colorectal cancer (CRC) is fortunately a rare condition in childbearing women, with an incidence of about 2.2-7.7 per 100,000 pregnancies . Due to the increasing incidence of CRC in young patients and a trend towards delayed childbearing with advanced maternal age, pregnancy-related CRC is likely to rise . ...
This study aimed to analyze disease presentation, management, and oncological outcomes of patients diagnosed with peripartum colorectal cancer (CRC).
Retrospective cohort study of all consecutive women of childbearing age (18–45 years) between 2002 and 2014 diagnosed with CRC adenocarcinoma at a tertiary academic institution. Patients who experienced pregnancy within 12 months of their diagnosis (peripartum period, group 1) were compared to the remaining patients of the cohort (group 2). Overall survival (OS) was compared between the two groups through Kaplan-Meier estimates.
Out of 555 consecutive women with a mean age of 37.8 + 6 years, 31 (5.6%) were diagnosed with CRC in the peripartum period. Of these, all patients were symptomatic during pregnancy due to bleeding, abdominal pain, or constipation; however, only 11 CRC (35.5%) were diagnosed during pregnancy, 1 (3.2%) during C section, and the remaining (61.3%) postpartum. TNM stage at presentation was I in 6 patients (19.4%), II in 4 patients (13.9%), III in 8 patients (25.8%), and IV in 13 patients (41.9%). Surgical resection was performed in 23 patients (74.2%): 2 while pregnant, 2 at the time of C section, and the remainder postpartum. Across all stages, OS was 95% at 1 year and 62% at 5 years and did not differ between the two comparative groups (p = 0.16).
A suspicious attitude towards cancer-related symptoms during pregnancy is crucial to prevent delayed evaluation for CRC.
... Our patient had experienced an intermittent abdominal pain all over her pregnancy with moderate anemia. Common presentations of CRC including abdominal pain, nausea, vomiting, anemia, and rectal bleeding usually masked by pregnancy and it is truly hard to distinguish these symptoms of what is considered as warning signs of CRC [2,. This delay would lead to late diagnosis of the disease and subsequently poor prognosis. ...
The aim of this study was to identify the mode of presentation and incidence of colorectal cancer in pregnancy (CRC-p), assess the outcomes of the mother and foetus according to gestational age, treatment delivered and cancer features and location. A systematic review of the literature was carried out to identify studies reporting on CRC-p and pooled analysis of the reported data. Seventy-nine papers reporting on 119 patients with unequivocal CRC-p were included. The calculated pooled risk is 0.002% and age at diagnosis has decreased over time. The median age at diagnosis was 32 (range, 17-46) years. Twelve per cent, 41 and 47% of CRC-p were diagnosed during the first, second and third trimester. The CRC-p site was the colon in 53.4% of cases, the rectum in 44% and multiple sites in 2.6%. Bleeding occurred in 47% of patients, abdominal pain in 37.6%, constipation in 14.1%, obstruction in 9.4% and perforation in 2.4%. Out of 82 patients whose treatment was described, 9.8% received chemotherapy during pregnancy. None of their newborns developed permanent disability, one developed hypothyroidism and 72% of newborns were alive. Vaginal delivery was possible in 60% of cases. Anterior resection was performed in 30% of patients and abdominoperineal excision of the rectum in 14.9%. Five patients had either synchronous (60%) or metachronous liver resection (40%). The median survival in these patients was 42 (0-120) months. Fifty-five per cent of patients were alive at the last available follow-up. The median survival of the mother was 36 (0-360) months. Patients with rectal cancer had longer survival compared with patients with colon cancer (P=0.0072). CRC-p is rare, leading to symptoms being overlooked, and diagnosis made at advanced stages. Cases described in the literature include patients who had cancer before pregnancy or developed it after delivery. Survival has not increased over time and the management of these patients requires collaboration between specialties and active interaction with the patients.
The need for abdominal surgery in the pregnant patient is not uncommon. The indication for non-obstetrical surgery during pregnancy should be approached in a similar fashion to the nonpregnant patient. While laparotomy has traditionally been used to address surgical disorders of the peritoneal cavity, the use of laparoscopy is a safe approach with many advantages and should be utilized, when appropriate. An understanding of the physiologic changes that occur during pregnancy is important to the operating surgeon, and anatomic alterations within the abdominal cavity will affect port placement. Proper patient positioning and fetal monitoring are also important in helping to prevent fetal loss during surgery. This chapter will discuss the use of laparoscopy in the pregnant patient with surgical disorders affecting the colon and rectum.
Colonic cancer during pregnancy is a rare event, whit incidence between 0.07 and 0.1%. Early diagnosis is difficult and prognosis is severe as it generally made at an advanced stage. We report a case of metastasic adenocarcinoma of the transverse colon in a 38-year-old pregnant patient diagnosed at 31 weeks of gestation. The problem of diagnosis as well as management of this pathology is discussed.
Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered.
Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population.
These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.
Although uncommon, the incidence of cancer complicating pregnancy is increasing. Managing these pregnancies creates many diagnostic, therapeutic, and ethical dilemmas for the patient, her family, and the medical care team. Despite concerns for fetal well-being, maternal survival should be the first priority. Although surgery and chemotherapy may be used during pregnancy, radiation is generally contraindicated. For most nongynecologic cancers, termination of pregnancy does not improve maternal outcome. Iatrogenic prematurity is the most common pregnancy complication associated with malignancy in pregnancy because many of these infants are delivered early to facilitate maternal treatment. Overall, maternal cancer survival is generally good and does not differ from that of nonpregnant patients.
El cáncer colorrectal asociado al embarazo es una patología extremadamente infrecuente. Se presenta el caso de una paciente de 38 años con antecedentes familiares de cáncer de colon, cursando un embarazo de 35 semanas en la que se diagnosticó un cáncer de colon derecho. Se efectúa una revisión de la literatura en relación al diagnóstico y manejo de esta rara entidad.
Cancer during pregnancy has increased due to delayed motherhood and the known occurrence of age-dependent malignant tumors. With the increase in colorectal cancer diagnosed in young adults, the number of cases during pregnancy is likely to increase. Colorectal cancer is one of the 3 most common types of cancer in women, but the occurrence during pregnancy is rare and is associated with a large number of diagnostic and therapeutic challenges since the diagnosis is usually made in advanced stages. Besides, early diagnosis is difficult because the signs/symptoms (vomiting, constipation, anemia, rectorrhagia, pain and bloating) can simulate those observed during pregnancy. After diagnosis, the therapeutic plan must be established immediately, according to gestational age, by a multidisciplinary medical team. Doctors who care for pregnant women with colorectal cancer face two problems: the need for early maternal cancer treatment and timing of pregnancy termination. Professionals must become familiar with the challenges associated with systemic treatment, since antineoplastic treatment presents several unknowns for its use.
Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases, the cancer and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.
Six cases of pregnancy associated malignant ovarian tumors, four epithelial cancers, one immature teratoma and one metastatic cancer of colon origin, are reported. One patient with mucinous cystadenocarcinoma had a history of persistent ovarian tumor during her past three pregnancies. Another patient was found to have mucinous cystadenocarcinoma after an emergency operation for twisted ovarian tumor. Immature teratoma associated with pregnancy is very rare and our case seems to be the 8th reported such case.
Colorectal carcinoma presenting in pregnancy is an uncommon disease that is reported to be associated with an extremely poor prognosis. To better characterize this disease, we surveyed the membership of the American Society of Colon and Rectal Surgeons by mailed questionnaire and reviewed the literature. Forty-one new cases of women with large bowel cancer who presented during pregnancy or the immediate postpartum period were identified. The mean age at presentation was 31 years (range, 16-41 years). Tumor distribution was as follows: right colon-3, transverse colon-2, left colon-2, sigmoid colon-8, and rectum-26. Dukes stage at presentation was A = 0, B = 16, C = 17, and D = 6 (two patients were unstaged). Average follow-up was 41 months. Stage for stage, survival was found to be similar to patients with colorectal tumors in the general population. Large bowel cancer coexistent with pregnancy presents in a distal distribution (64 percent of tumors in the current series and 86 percent of those reported in the literature were located in the rectum) and presents at an advanced stage (60 percent were Stage C or more advanced at the time of diagnosis). While patient survival is poor, it is no different stage for stage from the general population with colorectal tumors.
Carcinoma of the colon during pregnancy is rare. A 38-year-old woman with an obstructive adenocarcinoma of the left colon diagnosed at 27 weeks of gestation is described. Three months and 21 months after hemicolectomy a right, subsequently left ovariectomy was performed because of metastatic disease. Three years after initial surgery, which was followed by chemotherapy, the patient died of metastatic disease. Until now 26 cases of colon cancer during pregnancy have been described; none of these patients have survived 5 years. Metastatic spread of colon cancer to the ovaries in pregnant patients is frequently observed (25%). The fetal risk is very small, because placental and fetal involvement in maternal malignancy is rarely observed, even in widespread metastatic disease.
Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.
The reported incidence of cancer during pregnancy is between 0.07% and 0.1%. The incidence of colorectal carcinoma in pregnancy was 1 per 13,000 liveborn deliveries during 1981-1989.
A 33-year-old woman, gravida 2, para 1, was admitted at 30 weeks' gestational age with a history of rectal bleeding and right upper quadrant pain. Abdominal ultrasound and magnetic resonance imaging revealed a mass located on the posterior part of the right liver and a fetus with vertex presentation. Primary cesarean section and a right hemicolectomy and wedge biopsy from the metastatic lesion on the right side of the liver at 34 weeks' gestation was performed. Histologic examination confirmed serosal and lymph node invasion of moderately differentiated mucous-secreting adenocarcinoma of the cecum and adenocarcinoma metastatic to the liver. The patient received systemic chemotherapy.
Only 1 of 41 cases of colon cancer during pregnancy above the peritoneal reflection has been reported to be localized to the cecum. Our case is the second such one. Women with colorectal carcinoma during pregnancy usually have a poor prognosis, which may be attributable to younger age and delay in diagnosis since the initial symptoms often are presumed attributed to normal pregnancy, as in this case.
Colorectal carcinoma during pregnancy is a rare event. We report a 23-year-old primigravida with advanced stage adenocarcinoma of the sigmoid colon diagnosed at 34 weeks of gestation. A healthy female infant was delivered by cesarean section. The treatment of choice was chemotherapy. The patient died 3 months after delivery.
The medical community should become mobilized to diagnose colon cancer earlier in pregnancy to improve prognosis. The primary care physician or obstetrician should refer the pregnant patient with significant gastrointestinal complaints to the gastroenterologist for evaluation. Likewise, the gastroenterologist should be prepared to perform sigmoidoscopy, preferably without endoscopic medications, for significant lower gastrointestinal symptoms such as persistent rectal bleeding. Sigmoidoscopy is particularly sensitive in identifying colon cancer in pregnant patients because their cancers are usually distal and within reach of the sigmoidoscope.
Colon cancer during pregnancy. Gastroenter-ology Clinics of
Cappell MS. 2003. Colon cancer during pregnancy. Gastroenter-ology Clinics of North America 32:341 – 383.
E-mail: firstname.lastname@example.org DOI: 10.1080/01443610701241159 Figure 2. CT scan showing metastasis in the right lobe of liver (arrow)
Correspondence: J. Mechery, Department of Obstetrics & Gynaecology, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton, BL4 OJR, UK. E-mail: email@example.com DOI: 10.1080/01443610701241159 Figure 2. CT scan showing metastasis in the right lobe of liver (arrow).