Does pregnancy influence the prognosis of malignant melanoma?

Dermatologic and cosmetic procedures in pregnancy

Background:

Materials and Methods:

Results:

Pregnancy and melanoma

Malignant melanoma is the most common malignancy during pregnancy, and is diagnosed during childbearing age in approximately one-third of women diagnosed with melanoma. The impact of hormonal changes during pregnancy and from iatrogenic hormones on melanoma is controversial. Women undergo immunologic changes during pregnancy that may decrease tumor surveillance. In addition, hormone receptors are found on some melanomas. In spite of these observations, the preponderance of evidence does not support a poorer prognosis for pregnancy-associated melanomas. There is also a lack of evidence that oral contraceptives or hormone replacement therapy worsens melanoma prognosis.

A proposal for the timing of management of patients with melanoma presenting during pregnancy

The treatment of melanoma during and immediately after pregnancy poses a significant challenge to surgeons, oncologists, and patients alike. With the overall increase in incidence of melanoma in the United States and worldwide, it is likely that more surgeons will be faced with management decisions regarding pregnant patients with melanoma. We report on five patients who presented to the Yale Melanoma Unit with melanoma during their pregnancy. We propose the management option of resection of the primary tumor under local anesthesia, and postponing of the sentinel lymph node biopsy until after the birth of the child. The completion lymphadenectomy can be performed if these nodes are found to be harboring metastases. We further discuss treatment options and propose an algorithm for management of patients diagnosed with melanoma while pregnant.

Spontaneous regression of transplacental metastases from maternal melanoma in a newborn: case report and review of the literature

We describe a rare case of transplacental-transmitted maternal melanoma to the placenta and foetus during the second pregnancy of a 28-year-old woman. She was aware of a greyish-brown nodular lesion on the right gluteus during her first pregnancy. On histological examination, this lesion resulted to be an amelanocitic melanoma. Breast metastases occurred during her second pregnancy, 18 months after the surgical excision; an emergency Caesarean section performed for the recrudement of her clinical conditions confirmed widespread metastases to the liver, spleen and peritoneum. The patient died 2 weeks after delivery. The newborn, at 3 months of age, presented metastases secondary to maternal melanoma, which were resistant to chemotherapy. The disease regressed spontaneously and the child is now 24 months, alive in complete remission.

Case of metastatic melanoma in an epitrochlear lymph node arising in a pregnant woman

We describe a rare case of metastatic melanoma in an epitrochlear lymph node in a 29-year-old female patient. The patient had been aware of a brown macule on her right posterior forearm at puberty. Because the lesion had enlarged rapidly, she was referred to our hospital. Histological examination revealed a malignant melanoma. She underwent wide local excision with 3-cm margins and split thickness skin graft closure, but we were not able to perform sentinel node biopsy. She also received three cycles of systemic chemotherapy with dacarbazine, nimustine, vincristine and interferon-beta. However, an epitrochlear node (interval node) metastasis occurred during pregnancy (seventh week) 2 years after the operation. We emphasize that it is important for clinicians to pay attention to the possibility of epitrochlear node metastasis in patients with malignant melanoma in the upper extremity and that it is necessary to perform sentinel node biopsy to identify uncommon lymph node metastasis.

Nevi and melanoma in pregnancy

The influence of pregnancy on melanocytic nevi and malignant melanoma (MM) continues to be a controversial issue. Over the past 50 years, case reports and uncontrolled studies have suggested that nevi are more likely to become malignant during pregnancy, and MM diagnosed during pregnancy has a poor prognosis. Clinical and laboratory observations suggested that pregnancy-associated hormones may influence nevi and MM. Recent clinical and laboratory evidence suggests, however, that pregnancy does not influence the prognosis of MM, nor does it seem to cause significant changes in nevi. A clear link between hormones and MM has not been established. An analysis of this evidence is presented along with practical recommendations for the patient.

Pregnancy and Dermatologic Surgery

The physiologic changes of pregnancy and risks to the fetus require attention during dermatologic surgery. Elective surgery should be performed in the second trimester or the postpartum period. Cosmetic work should occur after delivery to avoid hypertrophic or hyperpigmented scars. Skin preparatory agents and anesthetics may have fetal implications and should be chosen with care. Antibiotic selection for any infections must take into account possible maternal and fetal risks. Attention to detail and awareness of the changes in pregnancy should lead to safe surgery in the pregnant patient.

Malignant Melanoma in Pregnancy

This article provides a concise overview of issues relating to melanoma and pregnancy, including pregnancy-associated risk and prognosis, and briefly summarizes results from relevant reports that have been published in recent years. The bulk of evidence amassed over the past half century suggests that pregnancy does not significantly affect the risk of developing malignant melanoma. Further, pregnancy does not seem adversely to influence overall survival from the disease. Most studies found no difference in overall survival between pregnant and nonpregnant women with melanoma. Recent reports from large-scale, population-based studies support these conclusions.

Malignant melanoma in pregnancy. A population-based evaluation

BACKGROUND

For many years, there has been controversy in the medical community regarding the correlation of female hormonal factors with the outcome of women with malignant melanoma. There have been multiple reports that women with high hormone states, such as pregnancy, had thicker tumors and/or a worse prognosis compared with a group of control women.

METHODS

The authors used a database that contained maternal and neonatal discharge records from the entire state of California from 1991 to 1999 and linked those records to the California Cancer Registry, which maintains legally mandated records of all cancers reported in California during the same time period. Four hundred twelve women with malignant melanoma diagnosed during or within 1 year after pregnancy were identified (145 antepartum, 4 at delivery, and 263 postpartum) and were compared with a group of age-matched, nonpregnant women with melanoma (controls). The database captured only pregnancies at > or = 20 weeks of gestation.

RESULTS

When comparing women who had pregnancy-associated melanoma with the control group, the authors found no difference in the distribution of disease stage (82.0% of pregnant and postpartum women had localized melanoma vs. 81.9% of control women) or the tumor thickness (mean: 0.77 mm for pregnant women, 0.90 mm for postpartum women, and 0.81 mm for the control group). In a multiple regression model that controlled for age, race, stage, and tumor thickness, pregnancy had no impact on survival in women with melanoma. Lymph node assessment and positivity of lymph nodes also were equivalent between the two groups. Maternal and neonatal outcomes did not differ between pregnant women with melanoma and control women who were pregnant and had no history of malignancy. Small numbers of women with advanced melanoma and the inability to capture melanoma that occurred in pregnancies that were lost or were terminated prior to 20 weeks limited the conclusions primarily to women with localized melanoma.

CONCLUSIONS

In this large, population-based study of pregnant women in California from 1991 to 1999 with malignant melanoma, there were no data found to support a more advanced stage, thicker tumors, increased metastases to lymph nodes, or a worsened survival. The outcome for women with localized melanoma associated with pregnancy was excellent. Maternal and neonatal outcomes also were equivalent to those of pregnant women without melanoma.

Malignant Melanoma Arising in a Pregnant African American Woman with a Congenital Blue Nevus

BACKGROUND

The incidence of cutaneous melanoma in African-Americans is relatively low. Despite the slightly greater occurrence of congenital melanocytic nevi in black persons compared with white persons, the cumulative risk of melanoma arising in these lesions is very small. In addition, the overwhelming majority of melanomas in black persons occur on nonglaborous skin where congenital melanocytic nevi are rare.

OBJECTIVE

The objective was to describe and an unusual case of melanoma arising in a congenital nevus with combined features of a blue nevus on the scalp of a pregnant African-American woman.

RESULTS

Histologic examination revealed a polypoid malignant melanoma arising in association with a congenital blue nevus in a young African-American woman. The lesion was located on the right parietal scalp and had been enlarging over the course of her pregnancy. Pathology from parotidectomy and neck dissection confirmed metastatic melanoma involving two intraparotid lymph nodes and 3 of 26 cervical lymph nodes. Despite aggressive chemotherapy, she died in 1 year after the diagnosis.

METHODS

A case is reported and the literature is reviewed.

CONCLUSION

Clinicians must take great care in documenting and following pigmented lesions in all patients including African-American persons. Excision is indicated for lesions that undergo significant change during pregnancy.

Cancer in pregnancy: maternal-fetal conflict

The occurrence of malignancies during pregnancy has increased over the last decades. They complicate approximately 1 per 1000 pregnancies. The most common malignancies associated with pregnancy include malignant melanoma, malignant lymphomas and leukemia, and cancer of the cervix, breast, ovary, colon and thyroid. Since it is impossible for prospective randomized clinical trials to be conducted in this field, relevant data have been generated from case reports and matched historical cohort studies in order to evaluate the treatment outcomes and the issues complicating the management of malignancy in the pregnant patient. There is almost always a conflict between optimal maternal therapy and fetal well-being. The maternal interest is for an immediate treatment of the recently diagnosed tumor. However, the optimal therapy, be it chemotherapy, radiotherapy or surgery, may impose great risks on the fetus. Consequently, either maternal or fetal health, or both, will be compromised. Therefore, both the pregnant patient and her physician are often in a dilemma as to the optimal course. On the basis of the medical facts, we discuss the issues raising potential ethical conflicts and present a practical ethical approach which may help to increase clarity in maternal-fetal conflicts. We review the available data informing the incidence and impact of the most common malignancies during pregnancy and their treatment on both the pregnant woman and her fetus. The optimal therapy for the tragic diagnosis of cancer in pregnancy requires a collaborative and interdisciplinary approach between gynecologists, oncologists, obstetricians, surgeons, neonatologists, psychologists, nursing staff and other disciplines. The purpose of this article is not to answer specific questions or to construct management schemes for specific tumors but to provide a framework for approaching some of these complex issues.

Focus on primary care: from nevus to neoplasm: myths of melanoma in pregnancy

Malignant melanoma is one of the few malignancies that regularly affect women during their childbearing years. Additionally, the incidence of melanoma has been increasing over the last several decades. Early diagnosis of stage I disease may lead to curative therapy; thus it is important for physicians and midwives to do a full examination of the skin. However, the myth that nevi may naturally grow or change during pregnancy has been shown not to be true and should not delay a diagnostic evaluation of a suspicious nevus. Older studies had theorized a worse outcome for pregnant women with melanoma. However, multiple controlled series and investigations have found that stage for stage this cancer is not affected adversely by pregnancy. Prognosis, recurrence, and incidence of melanoma seemed to be unaffected. Estrogen-containing oral contraceptives, as well as hormone replacement therapy, have no adverse affect on the disease.

17beta-estradiol, progesterone, and dihydrotestosterone suppress the growth of human melanoma by inhibiting interleukin-8 production

We studied the effects of 17beta-estradiol, progesterone, and dihydrotestosterone on in vitro growth of human metastatic melanoma. Each sex hormone inhibited the growth of melanoma receptor-dependently; 17beta-estradiol inhibited 3H-thymidine uptake of estrogen receptor-positive WM266-4 and NM26, but not that of the receptor-negative HS15. Progesterone inhibited 3H-thymidine uptake of progesterone receptor-positive WM266-4 and HS15, but not that of the receptor-negative NM26. Dihydrotestosterone inhibited 3H-thymidine uptake of androgen receptor-positive HS15 and NM26, but not that of the receptor-negative WM266-4. The growth inhibition by each hormone was counteracted by the respective hormone receptor antagonist. The combination of more than two hormones neither gave additive nor synergistic growth inhibition. The growth inhibition by each sex hormone was counteracted by interleukin-8 but not by the other growth factors. Each sex hormone reduced the constitutive interleukin-8 secretion and mRNA levels in the respective receptor-positive melanoma but not in the receptor-negative melanoma. Transient transfection showed that each sex hormone inhibited the constitutive chloramphenicol acetyltransferase expression driven by interleukin-8 promoter in the respective receptor-positive melanoma but not in the receptor-negative melanoma. Transfection with a series of 5'-deleted interleukin-8 promoter/chloramphenicol acetyltransferase reporter constructs demonstrated that the sequences between -98 and -63 bp on interleukin-8 promoter may be involved in the transcriptional repression. These data suggest that 17beta-estradiol, progesterone, and dihydrotestosterone suppress the growth of melanoma by inhibiting interleukin-8 production in a receptor-dependent manner.

Common dermatoses of pregnancy

Awareness of pregnancy-related skin changes can facilitate improved care of women during pregnancy by identifying those skin changes that require further evaluation. Women experience significant endocrine and metabolic changes during pregnancy that can cause both physiologic and pathologic alterations in the skin, nails, and hair. This review discusses the physiologic changes and pruritic dermatoses that are specifically associated with pregnancy. The effect of pregnancy on preexisting skin diseases and safe treatment options for usage during pregnancy will be provided.

Pregnancy and exogenous hormones in patients with cutaneous malignant melanoma

In this article, recent literature is reviewed with regard to possible hormonal influences on susceptibility to melanoma and prognosis once melanoma is developed. At the present time, there is little data to suggest that melanoma and pregnancy interact as far as prognosis is concerned for patients with stage 1 and stage 2 disease. Recent data have provided further reassurance that oral contraceptives are safe for patients who have had melanoma, and more data is required before a definitive statement can be made regarding hormone replacement therapy for women who have had stage 1 or 2 melanoma adequately treated.

Melanoma and pregnancy with placental metastases. Report of a case

The authors report on the case of a 33-year-old white woman who developed melanoma during pregnancy, with widespread metastatic disease involving the placenta. The melanoma developed during two consecutive pregnancies and was untreated throughout the course of both. The patient died with widespread metastases shortly after attempted Cesarean delivery of her second child. Histopathologic and immunohistochemical studies were made with anti-S-100 protein and HMB45 antibodies. The authors discuss the possible influence of pregnancy on the prognosis of melanoma.

Melanoma complicating pregnancy

The incidence of malignant melanoma is rising, and this may be the most frequently encountered malignancy during pregnancy. Because effective treatment of advanced or metastatic disease remains elusive, the key to adequate therapy is surveillance for early disease with prompt diagnostic work-up and treatment. Review of the most prominent reports in the literature fails to yield a consensus on whether pregnancy contributes to a worse prognosis. It seems clear that after controlling for all known prognostic variables, prognosis is unchanged; however, groups of patients diagnosed during pregnancy may have a disproportionately high incidence of high-risk primary lesion sites and increased tumor thickness. Surgical treatment during pregnancy should be prompt, with appropriate avoidance of general anesthesia during the first trimester. There is as yet insufficient evidence to warrant the use of adjuvant chemotherapy or biologic therapy during pregnancy.

HLA-G expression in melanoma: a way for tumor cells to escape from immunosurveillance

Considering the well established role of nonclassical HLA-G class I molecules in inhibiting natural killer (NK) cell function, the consequence of abnormal HLA-G expression in malignant cells should be the escape of tumors from immunosurveillance. To examine this hypothesis, we analyzed HLA-G expression and NK sensitivity in human malignant melanoma cells. Our analysis of three melanoma cell lines and ex vivo biopsy demonstrated that (i) IGR and M74 human melanoma cell lines exhibit a high level of HLA-G transcription with differential HLA-G isoform transcription and protein expression patterns, (ii) a higher level of HLA-G transcription ex vivo is detected in a skin melanoma metastasis biopsy compared with a healthy skin fragment from the same individual, and (iii) HLA-G protein isoforms other than membrane-bound HLA-G1 protect IGR from NK lysis. It thus appears of critical importance to consider the specific role of HLA-G expression in tumors in the design of future cancer immunotherapies.

Staging and prognosis of melanoma

Prognosis and survival for patients diagnosed with melanoma depends on a number of interrelated factors, including histological, clinical, immunologic, and surgical parameters. Tumor thickness and depth of invasion is the most important prognostic factor, and helps to guide treatment and management plans. Besides tumor thickness, other histological criteria include melanoma growth phase (nodal v. vertical), host response, angiolymphatic invasion, mitotic rate, regression, satellitosis, and neurotropism. Important clinical prognostic factors include anatomic location of the melanoma and the patient's age and sex. Surgical factors to be examined involve excisional margin size, and elective lymph node dissection. Finally, the staging of patients with melanomas (nodal or visceral metastases) helps to define survival.

Hepatocellular carcinoma during pregnancy and its comparison with other pregnancy-associated malignancies

BACKGROUND

Cancer in pregnancy is rare and hepatocellular carcinoma (HCC) in pregnancy even rarer. The impact of pregnancy on the prognosis of patients with different types of cancer remains controversial. Reported cases of HCC in pregnancy are largely isolated and highly scattered. Thus, the effect of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC in pregnancy are not well documented.

METHODS

A series of five patients with HCC in pregnancy seen at two different centers is reported. A Medlar search for articles between 1957 and 1993 with the key words "Hepatocellular Carcinoma" and "Pregnancy" was conducted. All reported cases were combined and analyzed in terms of race, age, parity, hepatitis B surface antigen status, cirrhosis, serum alpha-fetoprotein (AFP) levels at presentation, history of taking oral contraceptive pills and fetal and maternal outcome. The impact of pregnancy on 12 other malignancies as reported in the medical literature also was reviewed.

RESULTS

To the authors' knowledge, The five cases reported here constitute the largest series of HCC in pregnancy. A literature search revealed 23 additional cases. Analysis of the 28 cases suggests that the rarity of HCC in pregnancy results from a combination of three factors: the male predominance of HCC, the late age at which the tumor usually presents in women, and decreased fertility in women with advanced cirrhosis (hepatitis is a predisposing factor for HCC development). Long term use of oral contraceptives and high parity enhance the risk. Elevated AFP level is useful for diagnosis. The median survival is shorter than for patients who are not pregnant. There is no significant difference in survival between pregnant and not pregnant women matched by tumor stage, age, and other clinical parameters in most malignancies except in some tumors like lymphoma, thyroid cancer, and nasopharyngeal carcinoma.

CONCLUSION

Pregnancy has an adverse effect on the prognosis of patients with HCC, lymphoma, thyroid cancer, and nasopharyngeal carcinoma but not of most other malignancies. Measurement of AFP level is recommended for screening HCC in pregnant women at high risk.

Public education and cancer of the skin. What do people need to know about melanoma and nonmelanoma skin cancer?

Cutaneous melanoma (CM) and nonmelanoma skin cancer (NMSC) have a high chance for cure if detected in an early phase of development. Patients who have these tumors may now be treated in the outpatient setting with a minimum of discomfort, inconvenience, and cost. Most skin cancer deaths are caused by CM. Until recently, CM incidence in the United States has been increasing faster than any other potentially lethal cancer, attributable at least in part to aggressive case detection and greater public awareness about the significance of risk factors and early warning signs of evolving tumors, resulting in increased numbers of curable tumors. Most CMs are discovered by patients or close acquaintances. Most CM deaths are related to patient delay in seeking medical care. Patient delay is attributed mostly to lack of knowledge rather than to fear and denial. In the United States, primary prevention of CM and NMSC has focused on encouraging sensible sun-exposure behaviors, while secondary prevention consists of a yearly national campaign that promotes skin awareness and self-examination and free examinations to detect evolving tumors, sponsored by the American Academy of Dermatology and the American Cancer Society. More attention is needed to encourage timely consultation for evolving tumors and predisposing risk factors and to focus screening and surveillance efforts of those people at greatest risk. Public education must continue to promote personal responsibility in the intervention process to reduce the morbidity and mortality associated with CM and NMSC.