SAN DIEGO — A pregnant patient's suspicious or changing skin lesion should be investigated as promptly and as thoroughly as the same lesion in a nonpregnant patient, Dr. Dina Massry said at a melanoma update sponsored by the Scripps Clinic.
Studies pointing to delayed diagnosis of melanoma among pregnant patients “clearly illustrate that physicians should treat changing nevi in pregnant women exactly the same as in their nonpregnant patients, and biopsy promptly,” said Dr. Massry, head of the division of dermatology at the clinic's Green Hospital in La Jolla, Calif.
Although pregnancy itself does not increase a woman's risk of melanoma, the evidence consistently shows that pregnant women present with later-stage disease and more frequent nodal metastasis. This often occurs because suspicious lesions are dismissed as normal changes of pregnancy, she said in an interview.
“If you or your patient notes a changing mole, don't delay what you would normally do because she is pregnant, and don't ascribe the change as a normal phenomenon of pregnancy,” she said.
As with nonpregnant patients, the prognosis for melanoma depends on the thickness of the lesion and evidence of ulceration. Surgical excision remains the best management. Late-stage melanoma can be lethal, however, and even though metastatic disease rarely has an impact on the fetus, treatment considerations in such cases must weigh the survival prognosis of both the mother and the fetus, she said.
“Consideration has to be given to whether the mother will even survive to delivery, as well as whether the cancer will metastasize to the placenta or the fetus,” she said, adding that, in such rare cases, it might be reasonable to broach the topic of pregnancy termination with the patient.
“Also, the pregnancy itself is going to change the woman's treatment options. She could theoretically have more aggressive treatment if she were not pregnant,” Dr. Massry noted.
Metastasis of melanoma to the fetus is extremely rare. Only 1 in 1,000 pregnancies is affected by cancer, and just 8% of these cancers are melanoma, she said. However, of all cancers, melanoma is the most likely to spread to the products of conception—with one-third metastasizing to either the placenta or the fetus.
In the most recent literature review of 87 cases of fetal or placental metastasis, 27 cases were attributed to melanoma. Six of those 27 cases actually affected the fetus, with the remaining 21 showing placental metastasis only (J. Clin. Oncol. 2003;21:2179–86).
Among the cases of fetal metastasis, five of the infants died within the first year of life; in the sixth infant, lung and soft tissue metastasis spontaneously regressed for at least 14 years, she said.
Among the cases of placental metastasis, three infants died within 2 days of birth from causes not directly related to metastatic melanoma. Follow-up of the other 18 cases showed no evidence of disease within a range of 47 days to 2 years.
The timing of pregnancy after treatment for melanoma has no impact on recurrence, Dr. Massry said.
Patients can be advised that disease recurrence is primarily related to tumor thickness. A study of 43 women who became pregnant within 5 years of a melanoma diagnosis found no difference in their survival, compared with age-matched controls who became pregnant more than 5 years after their diagnosis (Cancer 1985;55:340–4).