Opinion Article
Melanoma and Pregnancy
Melanoma y embarazo
S. Serrano-Ortega
, A. Buendía-Eisman
Autor para correspondencia
Professor of Dermatology, Universidad de Granada, Granada, Spain
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Borges, S. Puig, J. Malvehy" "autores" => array:3 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Borges" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Puig" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Malvehy" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731011000780" "doi" => "10.1016/j.ad.2011.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731011000780?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219011000904?idApp=UINPBA000044" "url" => "/15782190/0000010200000009/v1_201304241238/S1578219011000904/v1_201304241238/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Opinion Article</span>" "titulo" => "Melanoma and Pregnancy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "647" "paginaFinal" => "649" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Serrano-Ortega, A. Buendía-Eisman" "autores" => array:2 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Serrano-Ortega" "email" => array:1 [ 0 => "consultadermatologia@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Buendía-Eisman" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Professor of Dermatology, Universidad de Granada, Granada, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Melanoma y embarazo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have often heard and still hear statements like “If you have had melanoma you should not get pregnant” or “If you are pregnant and you develop melanoma, your pregnancy has to be terminated”. We have even made such statements ourselves, whether to prevent the recurrence of hypothetically residual disease or to avoid a poor prognosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There has been a great deal of controversy over the years regarding the links between cutaneous melanoma and pregnancy. Given the existence of studies that argue for and against a worse prognosis, it is essential to draw on sufficient data to be able to decide the most suitable approach to melanoma in pregnant women.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The incidence of melanoma is increasing steadily in most developed countries, whereas the birth rate is falling. In Spain the highest incidence of cutaneous melanoma is 11.9 cases per 100 000 population for males in Zaragoza, and 8.7 cases per 100 000 population for women in Tarragona; the lowest incidence, for both men and women, is in Cuenca, with 3.3 and 2 cases per 100 000 population, respectively.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 2009 in Spain, the average number of births per 1000 inhabitants was 10.75, ranging from 18.07 in Melilla to 7.76 in Asturias.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The incidence of melanoma during pregnancy ranges from 2.8 to 8.5 cases per 100 000 pregnant women.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The estimated incidence of cancer during pregnancy is 1 case per 1000 pregnancies—the most frequent being cervical cancer, breast cancer, melanoma, lymphoma, and acute leukemia.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Pregnancy may affect prognosis and treatment, and there may be fetal involvement, due both to the disease and the treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The debate over the possible negative link between pregnancy and cutaneous melanoma began in 1951 with the publication of an article in <span class="elsevierStyleItalic">Cancer</span> by Pack and Scharnagel,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> who described a series of 10 pregnant women with melanoma, half of whom died within 2 to 30 months. Subsequent studies seemed to confirm this poor prognosis, giving possible hormonal influences as the explanation. However, these studies lacked scientific rigor, as they failed to take into account other prognostic factors or to draw comparisons with control groups. The first case-control studies, dating from the mid-1980<span class="elsevierStyleHsp" style=""></span>s, demonstrated that survival was comparable for similarly aged pregnant and nonpregnant women with melanoma.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> Today we can say, with a certain margin of certainty, that pregnancy does not alter melanoma prognosis.Published in this issue of <span class="elsevierStyleItalic">Actas Dermosifiliográficas</span> is an excellent review by Borges et al,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> which depicts the various scenarios that arise regarding a pregnant woman with pigmented lesions: changes in nevi; melanomas diagnosed during, before, and after pregnancy; and the use of oral contraceptives or hormone replacement therapy. This excellent review has inspired our commentary below.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Changes in nevi.</span> Skin pigmentation may change or darken, and nevi may change or grow during pregnancy. As a broadly applied generalization, however, this statement is potentially dangerous. This is because a changing or new nevus during pregnancy may be interpreted as a ‘normal’ aspect of pregnancy, when, in fact, it could mark the onset of cutaneous melanoma that is actually diagnosed when it is thicker, and therefore indicative of a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> We are of the opinion that pregnant women—like those who are not pregnant—with numerous moles or dysplastic nevi should be monitored, and biopsies should be performed if there are any suspicious changes.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Influence of pregnancy on skin melanoma.</span> There is no difference in the prognosis for women diagnosed with skin melanoma—irrespective of whether or not they are pregnant—once the diagnosis is adjusted to take into account tumor thickness and development stage.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">The repercussions of pregnancy on the natural history of cutaneous melanoma can be explained in 2 ways: the overall increase in melanoma incidence and the influence exerted by hormones.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A recent study demonstrated an annual 2.7% increase in the incidence of cutaneous melanoma in women aged between 15 and 39 years, with exposure to UV radiation identified as the main cause.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> The incidence of melanoma in women doubles with every 10 additional years of life; thus, for women of childbearing age, women aged 20-30 years account for 5% of all women diagnosed with melanoma, those aged 30-39 years for 11%, and those aged 40-49 years for 19%.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> A frequent practice nowadays is for women to postpone motherhood for career reasons, or, as often happens, for women to start a new family after the age of 35-40 years. According to the National Institute of Statistics,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> there were 486 127 births in Spain in 2009. These births showed an increasing distribution up to age 31-35 years: 4.1% for women in the 15-20 age bracket, 11% for the 21-25 age bracket, 25.85% for the 26-30 age bracket, and 37.8% for the peak 31-35 age bracket. There was then a drop to 24% for those in the 36-40 age bracket.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A prospective cohort study examined the possible links between gynecological history and cutaneous melanoma.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> No differences in risk were found between nulliparous women and women who had given birth 1 or more times, and no association was found between age during the first or last pregnancy and the risk of skin melanoma. In contrast, a lower risk was reported for women whose menarche commenced after 15 years (RR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.67, 95% CI: 0.46-0.49), and for women with irregular menstrual cycles. There were no differences in risk associated with age at menopause.</p><p id="par0060" class="elsevierStylePara elsevierViewall">There is sufficient evidence available to indicate that pregnancy does not alter the melanoma prognosis, irrespective of whether the cutaneous melanoma develops before, during, or after pregnancy.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, since melanoma recurrence is more frequent in the first 3 years post-intervention, high-risk patients should be advised to wait 3 years before becoming pregnant.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Melanoma treatment during pregnancy.</span> The main goal is to avoid complications for the mother and fetus. Surgical treatment is theoretically not contraindicated. Once a diagnosis is established, the tumor along with a surgical margin is removed, and the wound is closed applying the general principles of surgical dermatology. In our hospital we proceed as follows. We first check that the fetus is alive, if possible by means of a gynecological examination on the same day as surgery. We always use local anesthesia (lidocaine or mepivacaine without adrenaline). General anesthesia is usually not necessary if the tumor is small and reconstruction is possible by drawing the wound edges together or use of a small local flap. For more serious surgery, we use general anesthesia, but also locally infiltrate the surgery site with lidocaine or mepivacaine without adrenaline, as this means we can reduce post-operative analgesia. Anesthetic drugs can be safely used after the first trimester.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">When indicated, a sentinel node biopsy can be performed. The International Committee on Radiological Protection considers risk to be negligible for a dose of less than 1 mSv for the radiotracer, and for a dose of about 0.4 mSv during the sentinel node biopsy.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The time elapsing between radiocolloid injection and surgery should be kept to a minimum. In our hospital we inject the radiocolloid, perform the lymphoscintigraphy, and immediately dispatch the patient to surgery, all within an hour.</p><p id="par0075" class="elsevierStylePara elsevierViewall">When lymphadenectomy is necessary, modern anesthesia techniques are such that surgery can be performed without any problems for the mother or the fetus.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, current knowledge indicates that melanoma does not contraindicate pregnancy, and that pregnancy should not alter the therapeutic approach to skin melanoma.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 13 | 22 |
| 2024 Octubre | 78 | 40 | 118 |
| 2024 Septiembre | 92 | 29 | 121 |
| 2024 Agosto | 123 | 43 | 166 |
| 2024 Julio | 99 | 34 | 133 |
| 2024 Junio | 94 | 33 | 127 |
| 2024 Mayo | 95 | 27 | 122 |
| 2024 Abril | 81 | 26 | 107 |
| 2024 Marzo | 80 | 24 | 104 |
| 2024 Febrero | 74 | 26 | 100 |
| 2024 Enero | 81 | 40 | 121 |
| 2023 Diciembre | 53 | 21 | 74 |
| 2023 Noviembre | 69 | 27 | 96 |
| 2023 Octubre | 69 | 15 | 84 |
| 2023 Septiembre | 73 | 32 | 105 |
| 2023 Agosto | 41 | 17 | 58 |
| 2023 Julio | 63 | 29 | 92 |
| 2023 Junio | 66 | 19 | 85 |
| 2023 Mayo | 74 | 23 | 97 |
| 2023 Abril | 66 | 23 | 89 |
| 2023 Marzo | 52 | 36 | 88 |
| 2023 Febrero | 44 | 12 | 56 |
| 2023 Enero | 59 | 26 | 85 |
| 2022 Diciembre | 61 | 51 | 112 |
| 2022 Noviembre | 18 | 37 | 55 |
| 2022 Octubre | 29 | 19 | 48 |
| 2022 Septiembre | 27 | 23 | 50 |
| 2022 Agosto | 26 | 34 | 60 |
| 2022 Julio | 32 | 33 | 65 |
| 2022 Junio | 27 | 22 | 49 |
| 2022 Mayo | 38 | 32 | 70 |
| 2022 Abril | 63 | 34 | 97 |
| 2022 Marzo | 49 | 55 | 104 |
| 2022 Febrero | 42 | 30 | 72 |
| 2022 Enero | 37 | 39 | 76 |
| 2021 Diciembre | 27 | 34 | 61 |
| 2021 Noviembre | 41 | 39 | 80 |
| 2021 Octubre | 40 | 40 | 80 |
| 2021 Septiembre | 29 | 36 | 65 |
| 2021 Agosto | 35 | 26 | 61 |
| 2021 Julio | 39 | 29 | 68 |
| 2021 Junio | 30 | 25 | 55 |
| 2021 Mayo | 32 | 48 | 80 |
| 2021 Abril | 89 | 52 | 141 |
| 2021 Marzo | 63 | 30 | 93 |
| 2021 Febrero | 50 | 19 | 69 |
| 2021 Enero | 37 | 18 | 55 |
| 2020 Diciembre | 43 | 16 | 59 |
| 2020 Noviembre | 29 | 18 | 47 |
| 2020 Octubre | 15 | 22 | 37 |
| 2020 Septiembre | 32 | 7 | 39 |
| 2020 Agosto | 25 | 18 | 43 |
| 2020 Julio | 17 | 11 | 28 |
| 2020 Junio | 37 | 30 | 67 |
| 2020 Mayo | 26 | 20 | 46 |
| 2020 Abril | 39 | 20 | 59 |
| 2020 Marzo | 26 | 27 | 53 |
| 2020 Febrero | 2 | 7 | 9 |
| 2020 Enero | 0 | 5 | 5 |
| 2019 Diciembre | 4 | 2 | 6 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 0 | 5 | 5 |
| 2019 Julio | 0 | 2 | 2 |
| 2019 Junio | 2 | 5 | 7 |
| 2019 Mayo | 0 | 12 | 12 |
| 2019 Abril | 0 | 5 | 5 |
| 2019 Marzo | 2 | 6 | 8 |
| 2019 Febrero | 0 | 6 | 6 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 1 | 0 | 1 |
| 2018 Octubre | 1 | 1 | 2 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Marzo | 1 | 2 | 3 |
| 2018 Febrero | 25 | 2 | 27 |
| 2018 Enero | 43 | 6 | 49 |
| 2017 Diciembre | 44 | 9 | 53 |
| 2017 Noviembre | 43 | 5 | 48 |
| 2017 Octubre | 30 | 5 | 35 |
| 2017 Septiembre | 27 | 6 | 33 |
| 2017 Agosto | 32 | 6 | 38 |
| 2017 Julio | 29 | 3 | 32 |
| 2017 Junio | 41 | 23 | 64 |
| 2017 Mayo | 40 | 7 | 47 |
| 2017 Abril | 33 | 19 | 52 |
| 2017 Marzo | 24 | 31 | 55 |
| 2017 Febrero | 41 | 12 | 53 |
| 2017 Enero | 31 | 4 | 35 |
| 2016 Diciembre | 41 | 5 | 46 |
| 2016 Noviembre | 56 | 5 | 61 |
| 2016 Octubre | 56 | 12 | 68 |
| 2016 Septiembre | 55 | 11 | 66 |
| 2016 Agosto | 53 | 15 | 68 |
| 2016 Julio | 43 | 12 | 55 |
| 2016 Junio | 15 | 13 | 28 |
| 2016 Mayo | 8 | 10 | 18 |
| 2016 Abril | 5 | 2 | 7 |
| 2016 Marzo | 7 | 1 | 8 |
| 2016 Febrero | 7 | 3 | 10 |
| 2016 Enero | 16 | 1 | 17 |
| 2015 Diciembre | 13 | 1 | 14 |
| 2015 Noviembre | 20 | 1 | 21 |
| 2015 Octubre | 16 | 3 | 19 |
| 2015 Septiembre | 15 | 2 | 17 |
| 2015 Agosto | 15 | 7 | 22 |
| 2015 Julio | 44 | 16 | 60 |
| 2015 Junio | 63 | 18 | 81 |
| 2015 Mayo | 85 | 8 | 93 |
| 2015 Abril | 61 | 13 | 74 |
| 2015 Marzo | 65 | 9 | 74 |
| 2015 Febrero | 45 | 8 | 53 |
| 2015 Enero | 47 | 12 | 59 |
| 2014 Diciembre | 60 | 16 | 76 |
| 2014 Noviembre | 31 | 9 | 40 |
| 2014 Octubre | 51 | 9 | 60 |
| 2014 Septiembre | 42 | 16 | 58 |
| 2014 Agosto | 47 | 10 | 57 |
| 2014 Julio | 74 | 15 | 89 |
| 2014 Junio | 80 | 11 | 91 |
| 2014 Mayo | 105 | 13 | 118 |
| 2014 Abril | 77 | 10 | 87 |
| 2014 Marzo | 99 | 17 | 116 |
| 2014 Febrero | 54 | 12 | 66 |
| 2014 Enero | 58 | 14 | 72 |
| 2013 Diciembre | 59 | 16 | 75 |
| 2013 Noviembre | 45 | 20 | 65 |
| 2013 Octubre | 18 | 9 | 27 |
| 2013 Septiembre | 14 | 7 | 21 |
| 2013 Agosto | 20 | 11 | 31 |
| 2013 Julio | 19 | 23 | 42 |
| 2013 Junio | 11 | 17 | 28 |
| 2013 Mayo | 8 | 45 | 53 |
| 2013 Abril | 12 | 14 | 26 |
| 2013 Marzo | 19 | 9 | 28 |
| 2013 Febrero | 34 | 8 | 42 |
| 2013 Enero | 17 | 4 | 21 |
| 2012 Diciembre | 16 | 7 | 23 |
| 2012 Octubre | 0 | 1 | 1 |
| 2012 Agosto | 2 | 0 | 2 |
| 2012 Julio | 1 | 0 | 1 |
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