Elsevier

Clinics in Dermatology

Volume 27, Issue 1, January–February 2009, Pages 116-121
Clinics in Dermatology

Nevi and melanoma in the pregnant woman

https://doi.org/10.1016/j.clindermatol.2008.09.009Get rights and content

Abstract

Multiple difficult questions arise when a pregnant woman presents to the dermatologist with a changing melanocytic nevus or melanoma. Our review of the literature provides some insight into these issues. We recommend that a changing pigmented lesion in the pregnant woman should be biopsied promptly and can be safely performed. Women who have dysplastic nevus syndrome require closer monitoring during pregnancy. For the pregnant woman with a confirmed, localized melanoma, prognosis does not appear to be affected by pregnancy. Likewise, limited data indicate that pregnancy before or after a diagnosis of melanoma does not affect prognosis. Wide local excision may be performed safely, but if sentinel lymph node mapping and biopsy is indicated, the technique and safety of this procedure in the pregnant woman remains controversial. There appears to be no absolute contraindication to the prescription of oral contraceptive pills or hormone replacement therapy in someone who has been previously diagnosed with melanoma if no reasonable alternative exists.

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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