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Malignant melanoma: the adverse effect of pregnancy
ooO7-1276/81/0212-0338 %02.00
British Journal oJ”PIastic Surgery (1981) 34, 338-339 Q 1981 The Trustees of British Association of Plastic Surgeons
<
Malignant C. RIBERTI, Institute
melanoma:
G. MAROLA
and
of Plastic and Reconstructive
the adverse effect of pregnancy
A. BERTANI Surgery, University
The obvious pigmentary changes occurring in the skin of the face, abdomen and areola during pregnancy and the demonstration of increased melanocyte-stimulating substances in the blood and urine of pregnant women (Antes and Pomerantz, 1974; Dahlberg, 1961) suggest a possible relationship between pregancy and malignant melanoma (Lerner et al., 1954; Stewart, 195.5; Sadoff et al., 1973). Clinical reports in the literature are somewhat ambivalent. Most authors have found no statistically significant differences in the five-year survival rate between pregnant and nonpregnant patients with Stage I melanoma (George et al., 1960; Shiu et al., 1976; Smith and Randall, 1969; White et al., 1961). By contrast, other authors (George et al., 1960; Pack and Scharnagel, 1951) have reported a higher incidence of Stage II melanoma in pregnant women than in control cases with a significantly worse prognosis. We report a case in which there would appear to have been a clear relationship between the development of malignant change in a preexisting mole and pregnancy.
of Parma, Parma, Italy
Fig. 1 Ulcerated, nodular malignant melanoma (4 x 2 cm in size) over the forearm. ulcerated and enlarged glands could be felt in the axilla on the same side. At operation a few days later the lesion over the forearm was excised with a 5-cm margin of clearance and the deep fascia was included. The defect was skin grafted. In the excised specimen a discrete pigmented nodule was found in the subcutaneous tissues proximal to the primary lesion. At the same time, an axillary lymph node dissection was carried out. Histological examination confirmed malignant melanoma (Clark grade 5) at the primary site and malignant melanoma deposits in the subcutaneous nodule and in 5 of 12 lymph glands examined in the right axilla. Wound healing was uneventful and the patient is now receiving anti-tumour chemotherapy with DTlC (Marola and Rizzoli, 1978). The explosive transformation of a congenital mole into a rapidly growing malignant melanoma during early pregnancy and the equally sudden remission of the symptoms at the time of a miscarriage at three months, suggest a possible relationship between pregnancy and malignant change in a hitherto benign lesion. There is little doubt that pigmented naevi should be carefully observed during pregnancy. Any suspicious change in a pigmented lesion should be treated seriously and promptly by adequate excision biopsy and histological examination. Although regression in a malignant melanoma after pregnancy has
Case Report patient was a 34-year-old housewife with no history of any significant illness or disease. She gave a history of three perfectly normal pregnancies. A fourth child was stillborn. During the first weeks of her fifth pregnancy she had noticed that a tiny mole on the right forearm was suddenly and rapidly increasing in Our
size. The mole, which had been no larger than 2 x 4mm and had remained dormant since birth, now showed surface ulceration, had bled a little and was extremely irritable. At the third month of pregnancy the patient had a spontaneous miscarriage. Almost immediately our patient noted that the mole “stopped growing”. There was no further bleeding and the local irritation disappeared completely. Two months later when she was referred to our unit there was a raised nodular and hyper-pigmented mass 5 x 4 cm in size on the dorsal surface of the forearm (Fig. 1). The surface was 338
MALIGNANT
MELANOMA:
THE ADVERSE
EFFECT
OF PREGNANCY
been reported (Allen, 1955; Summer, 1953) young women recently treated for malignant melanoma should be urged to avoid pregnancy for three to five years to allow a reasonable period to elapse during which there could be a better prospect of the disease being eliminated by immunological influences.
Alien, E. P. (1955). Malignant melanoma: spontaneous regression after pregnancy. British Medical Journal, 2, 1067. Antes, I. G. and Pomerantz, S. H. (1974). Serum concentration of B-melanocyte-stimulating hormone in human pregnancy. American Journal of Obstetrics and Gynecology, 119, 1062. Dal&erg, B. C. (1961). Melanocyte-stimulating substances in the urine of pregnant women. Acta Endocrinologica, 38. Suppl. 60. (Copenhagen). George, P. A., Fortner, J. G. and Pack, G. T. (1960). Melanoma with pregnancy: A report of 115 cases. Cancer, 13, 854. Lerner, A. B., Schizume, K. and Bundiag, L. (1954). The mechanism of endocrine control of melanin pigmentation. Journal of Clinical Endocrinology, 14, 1463. Marola, G. and Rizzoli, V. (1978). Immunochemioterapia de1 melanoma maligno. Atti de1 XXVII Congress0 della Societa Italiana di Chirurgia Plastica-Parma. Pack, G. T. and Scharnagel, I. M. (1951). The prognosis for malignant melanoma in pregnant women. Cancrr. 4, 324.
339
Sadoff, L., Winkley, J. and Tyson, S. (1973). Is malignant melanoma an endocrine-dependent tumor? The possible adverse effect of estrogen. Oncology, 27, 244. Shiu, M. H., Schottenfeld, D., Maclean, B. and Fortoer, J. G. (1976). Adverse effects of pregnancy on melanoma. Cancer, 37, 181. Smith, R. S. and Randall, P. (1969). Melanoma during pregnancy. Surgery, Gynecology and Obstetrics, 34, 825. Stewart, H. (1955). A case of malignant melanoma and pregnancy. British Medical Journal, 1, 647. Summer, W. C. (1953). Spontaneous regression of melanoma: Case report. Cancer, 6, 1040. White, L. P., Linden, G., Breslow, L. and Harzfeld, L. (1961). Studies on melanoma: the effect of pregnancy on survival in human melanoma. Journal of American Medical Association, 177, 235.
The Authors C. Riherti, G. Marola, A. Bertani, Istituto di Ustionati, Regionale.
MD. MD. MD. Chirurgia Plastica e Ricostruttiva e Centro Grandi Universita degli Studi di Parma, Ospedale Parma. (Director: Professor A. Azzolini).
Requests for reprints to: Dr C. Riberti, Istituto Plastica. Via A. Gramsci 14, 43100 Parma.
di Chirurgia
British Journal oJ”PIastic Surgery (1981) 34, 338-339 Q 1981 The Trustees of British Association of Plastic Surgeons
<
Malignant C. RIBERTI, Institute
melanoma:
G. MAROLA
and
of Plastic and Reconstructive
the adverse effect of pregnancy
A. BERTANI Surgery, University
The obvious pigmentary changes occurring in the skin of the face, abdomen and areola during pregnancy and the demonstration of increased melanocyte-stimulating substances in the blood and urine of pregnant women (Antes and Pomerantz, 1974; Dahlberg, 1961) suggest a possible relationship between pregancy and malignant melanoma (Lerner et al., 1954; Stewart, 195.5; Sadoff et al., 1973). Clinical reports in the literature are somewhat ambivalent. Most authors have found no statistically significant differences in the five-year survival rate between pregnant and nonpregnant patients with Stage I melanoma (George et al., 1960; Shiu et al., 1976; Smith and Randall, 1969; White et al., 1961). By contrast, other authors (George et al., 1960; Pack and Scharnagel, 1951) have reported a higher incidence of Stage II melanoma in pregnant women than in control cases with a significantly worse prognosis. We report a case in which there would appear to have been a clear relationship between the development of malignant change in a preexisting mole and pregnancy.
of Parma, Parma, Italy
Fig. 1 Ulcerated, nodular malignant melanoma (4 x 2 cm in size) over the forearm. ulcerated and enlarged glands could be felt in the axilla on the same side. At operation a few days later the lesion over the forearm was excised with a 5-cm margin of clearance and the deep fascia was included. The defect was skin grafted. In the excised specimen a discrete pigmented nodule was found in the subcutaneous tissues proximal to the primary lesion. At the same time, an axillary lymph node dissection was carried out. Histological examination confirmed malignant melanoma (Clark grade 5) at the primary site and malignant melanoma deposits in the subcutaneous nodule and in 5 of 12 lymph glands examined in the right axilla. Wound healing was uneventful and the patient is now receiving anti-tumour chemotherapy with DTlC (Marola and Rizzoli, 1978). The explosive transformation of a congenital mole into a rapidly growing malignant melanoma during early pregnancy and the equally sudden remission of the symptoms at the time of a miscarriage at three months, suggest a possible relationship between pregnancy and malignant change in a hitherto benign lesion. There is little doubt that pigmented naevi should be carefully observed during pregnancy. Any suspicious change in a pigmented lesion should be treated seriously and promptly by adequate excision biopsy and histological examination. Although regression in a malignant melanoma after pregnancy has
Case Report patient was a 34-year-old housewife with no history of any significant illness or disease. She gave a history of three perfectly normal pregnancies. A fourth child was stillborn. During the first weeks of her fifth pregnancy she had noticed that a tiny mole on the right forearm was suddenly and rapidly increasing in Our
size. The mole, which had been no larger than 2 x 4mm and had remained dormant since birth, now showed surface ulceration, had bled a little and was extremely irritable. At the third month of pregnancy the patient had a spontaneous miscarriage. Almost immediately our patient noted that the mole “stopped growing”. There was no further bleeding and the local irritation disappeared completely. Two months later when she was referred to our unit there was a raised nodular and hyper-pigmented mass 5 x 4 cm in size on the dorsal surface of the forearm (Fig. 1). The surface was 338
MALIGNANT
MELANOMA:
THE ADVERSE
EFFECT
OF PREGNANCY
been reported (Allen, 1955; Summer, 1953) young women recently treated for malignant melanoma should be urged to avoid pregnancy for three to five years to allow a reasonable period to elapse during which there could be a better prospect of the disease being eliminated by immunological influences.
Alien, E. P. (1955). Malignant melanoma: spontaneous regression after pregnancy. British Medical Journal, 2, 1067. Antes, I. G. and Pomerantz, S. H. (1974). Serum concentration of B-melanocyte-stimulating hormone in human pregnancy. American Journal of Obstetrics and Gynecology, 119, 1062. Dal&erg, B. C. (1961). Melanocyte-stimulating substances in the urine of pregnant women. Acta Endocrinologica, 38. Suppl. 60. (Copenhagen). George, P. A., Fortner, J. G. and Pack, G. T. (1960). Melanoma with pregnancy: A report of 115 cases. Cancer, 13, 854. Lerner, A. B., Schizume, K. and Bundiag, L. (1954). The mechanism of endocrine control of melanin pigmentation. Journal of Clinical Endocrinology, 14, 1463. Marola, G. and Rizzoli, V. (1978). Immunochemioterapia de1 melanoma maligno. Atti de1 XXVII Congress0 della Societa Italiana di Chirurgia Plastica-Parma. Pack, G. T. and Scharnagel, I. M. (1951). The prognosis for malignant melanoma in pregnant women. Cancrr. 4, 324.
339
Sadoff, L., Winkley, J. and Tyson, S. (1973). Is malignant melanoma an endocrine-dependent tumor? The possible adverse effect of estrogen. Oncology, 27, 244. Shiu, M. H., Schottenfeld, D., Maclean, B. and Fortoer, J. G. (1976). Adverse effects of pregnancy on melanoma. Cancer, 37, 181. Smith, R. S. and Randall, P. (1969). Melanoma during pregnancy. Surgery, Gynecology and Obstetrics, 34, 825. Stewart, H. (1955). A case of malignant melanoma and pregnancy. British Medical Journal, 1, 647. Summer, W. C. (1953). Spontaneous regression of melanoma: Case report. Cancer, 6, 1040. White, L. P., Linden, G., Breslow, L. and Harzfeld, L. (1961). Studies on melanoma: the effect of pregnancy on survival in human melanoma. Journal of American Medical Association, 177, 235.
The Authors C. Riherti, G. Marola, A. Bertani, Istituto di Ustionati, Regionale.
MD. MD. MD. Chirurgia Plastica e Ricostruttiva e Centro Grandi Universita degli Studi di Parma, Ospedale Parma. (Director: Professor A. Azzolini).
Requests for reprints to: Dr C. Riberti, Istituto Plastica. Via A. Gramsci 14, 43100 Parma.
di Chirurgia