Nevi and melanoma in the pregnant woman
Introduction
The pregnant woman with a history of a changing melanocytic nevus (MN) or confirmed diagnosis of melanoma presents the dermatologist with a number of challenges. Many questions have been posed:
- 1.
Do MN typically change in pregnant women?
- 2.
Do women diagnosed with melanoma during pregnancy have a poorer prognosis compared with women who are not pregnant?
- 3.
If a suspicious a MN or melanoma is diagnosed during pregnancy, should the approach to this patient's evaluation and management differ from the nonpregnant patient? In other words, can biopsy or excision of suspicious MN or confirmed melanomas be performed safely during pregnancy, or should such procedures be delayed until after delivery?
- 4.
How should we advise her concerning future pregnancies, and the use of oral contraceptive pills (OCPs) or hormonal replacement therapy (HRT)?
In this contribution, we review the literature on MN and melanoma in the pregnant woman, and we hope to provide answers and advice to the dermatologist faced with these difficult queries.
Section snippets
Nevi and the pregnant woman
Melanocytic nevi may enlarge and darken in color during pregnancy, possibly related to the influence of pregnancy-related hormones.1, 2, 3 There are a paucity of studies that address this question adequately. Published studies include those that report the pregnant woman's own observations along with histologic features of MN during pregnancy compared with nonpregnant controls,4, 5 prospective studies of the size of MN during the course of pregnancy using photography in women with dysplastic
Melanoma prognosis in the pregnant woman
Initial concerns that melanoma diagnosed during pregnancy predicted a grim prognosis dates back to case reports from more than 50 years ago.15, 16, 17, 18, 19 Early reports did not always consider the depth of the melanoma, which is clearly the most important prognostic factor. Multiple studies have been published since the 1980s that used appropriate control groups and considered stage of disease and Breslow depth in their analyses. When we considered only those studies that met these criteria,
Evaluation and management of nevi and melanoma in the pregnant woman
The evaluation of the pregnant woman with a suspicious pigmented lesion or confirmed melanoma is similar to that for the nonpregnant patient. Management is based on the degree of histologic atypia for the MN, or stage of disease for confirmed melanoma. Controversy persists, however, concerning the safety of various diagnostic and staging procedures for the pregnant woman and her fetus.
As discussed previously, a changing MN that occurs in the pregnant woman should not be considered as
Counseling the pregnant woman about future pregnancies
Two small case–control studies have not observed an effect on the prognosis of women who became pregnant after a diagnosis of localized melanoma.21, 26 In one study,21 43 women who became pregnant within 5 years of diagnosis of localized melanoma were compared with a control group of 337 women who did not become pregnant within 2 years of diagnosis of localized melanoma. No significant difference was noted in survival or DFI between the groups.21 Similar findings were reported in a study of 85
Counseling the pregnant woman about oral contraceptive or hormonal replacement therapy use after diagnosis of melanoma
Most of the studies that address OCP use and melanoma are epidemiologic studies that have evaluated the relationship between the incidence of melanoma and exposure to OCPs. During the past several decades, strong evidence has been collected to show that OCPs do not increase a woman's risk for melanoma. Both a recent pooled analysis of 10 case–control studies43 and a meta-analysis44 based on 3794 cases and 9442 controls, have reported no increased risk of malignant melanoma related to OCP use.
Conclusions
The topic of MN and melanoma in the pregnant woman presents many challenges for the clinician. Based on our review of the literature, we have attempted to provide some reasonable recommendations concerning such patients. First, a changing pigmented lesion in the pregnant woman should be approached in the same way as for any patient. Prompt biopsy is indicated and can safely be performed under local anesthesia. A woman with a history of DNS requires close monitoring, because her MN may have a
Drug names
Dacarbazine: DTIC-Dome
DIC: Imidazole Carboxamide
Lidocaine: Xylocaine
Uncited References
45
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Cited by (26)
Pregnancy and Melanoma: Recommendations for Clinical Scenarios
2018, International Journal of Women's DermatologyNevi and pregnancy
2016, Journal of the American Academy of DermatologyCitation Excerpt :While no adverse events have been documented in humans, studies in sheep and in vitro studies with human uterine arteries have shown that epinephrine at high doses can cause spasm and reduce flow through the uterine artery.23-25 For this reason, many advise to use lidocaine without epinephrine in pregnant patients.26 Lidocaine with epinephrine is actually classified as FDA category B, and while there are no studies supporting this, the likelihood of significant effect on the fetus is low.
Difficulties with diagnosis of malignancies in pregnancy
2016, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :Classic nevi and dysplastic nevi often become more atypical, and they show more melanocytic proliferation during pregnancy, mimicking a malignant melanoma (Fig. 5). Of note, although nevi and melanoma cells do not harbour hormone receptors, they seem to be oestrogen-responsive [66,67]. The pregnancy tumour of the gums or gingival pyogenic granuloma is a benign tumour-like proliferation of endothelial cells, probably to a non-specific infection [68].
Melanocytic nevi, melanoma, and pregnancy
2011, Actas Dermo-SifiliograficasMelanoma: A protective role of pregnancy? A case report and review of literature
2011, Annales de Chirurgie Plastique EsthetiquePlacental metastasis of melanoma: A new case and literature review
2010, Annales de Pathologie