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Placental metastasis from primary ocular melanoma: A case report
Placental metastasis from primary ocular melanoma: A case report Robert de W. Marsh, M.B, ChB, and Nei-Min Chu, MD Gainesville, Florida Ocular malignant melanoma, similar to the cutaneous variety, may metastasize to the placenta, almost always in the presence of widespread disease. The prognosis is poor, and there is a 25% risk of spread to the fetus. All women with a history of this disease should be informed of the risks when they are contemplating pregnancy. (AM J OBSTETGYNECOL1996;174:1654-5.)
Key words: Ocular melanoma, placenta, pregnancy
We report a case of primary ocular choroidal melanoma metastasizing to the liver, skeleton, and, most important, placenta during pregnancy. Case r e p o r t The patient, a 31-year-old woman, underwent enucleation of the right eye in March 1993 for a primary choroidal melanoma. It was thought that the tumor had been thoroughly excised and there was no evidence of metastasis. She was lost to follow-up and was seen again approximately 1 year later, pregnant, with a gestational age of 36 weeks. In addition to the usual symptoms of From the Department of Medicine, University ofFlorida. Receivedfor publication August 10, 1995; revised September28, 1995; accepted October19, 1995. Reprint requests:Robert de W. Marsh, MB, ChB, Department of Medicine, University of Florida, 1600 S.W. Archer Road, Rm. R4-114, Gainesville, FL 32610-0277. Copyright 9 1996 by Mosby-YearBook, Inc. 0002-9378/96 $5.00+ 0 6/1/70000
pregnancy, she complained of right flank and sacroiliac pain, and subsequent evaluation showed multiple metastatic lesions in the liver. After confirmation of fetal lung maturity by amniocentesis, oxytocin (Pitocin) induction was initiated and the baby was delivered uneventfully. Gross examination of the placenta did not show any evidence of metastatic disease. However, on microscopic examination (Fig. 1), nests of epitheloid and spindle cells were seen in the intervillous space surrounding multiple stem and tertiary villae. Some of these contained finely dispersed black-to-brown pigment and stained positively with S-100 and HMB45. This was consistent with metastatic melanoma involving the placenta. Examination of the fetus, by both physical examination and abdominal ultrasonography, was unable to detect any evidence of fetal involvement. The mother herself was evaluated by computed tomogTaphic scans of the head, chest, abdomen, and pelvis, a s well as a bone scan. The only additional finding was widespread skeletal involvement. Potential therapeutic interventions were discussed with the
Fig. 1. Placental involvement of metastatic melanoma. 1654
Goolsby and Harlass
Volume 174, Number 5 Am J Obstet Gynecol
family, but unfortunately the mother died within 3 weeks of massive thrombotic disease of the inferior vena cava and hepatic veins with subsequent emboli to the lungs. Comment
A review of the literature does not reveal any previously reported cases of ocular choroidal melanoma metastasizing to the placenta or fetus. There are, however, a number of reports of cutaneous melanoma and other maternal malignancies with placental spread?' ~ Placental metastasis almost always occurs in the presence of widespread hematogenous dissemination of disease and usually portends a poor prognosis for the mother. Malign a n t melanoma is disproportionately represented in this group of individuals, with 58% of all cases reported representing malignant melanoma, 2 but with only 8% of all malignancies in pregnant women estimated to be the result of melanoma. Fortunately, clinically detectable transplacental spread to the fetus occurs less frequendy and does not always result in the establishment of overt disease, with only 25% of at-risk infants dying of the disease. This is probably due to failure of the malignant cells to cross the placenta and to implant successfully in fetal tissue, perhaps partially because of immunologic rejection. Conflicting opinions have been expressed concerning the influence of pregnancy on the behavior of mela-
noma.1. 2 Although increased hormonal levels during pregnancy theoretically have deleterious effects, the aggregate results from a n u m b e r of studies indicate that there is no net effect on tumor kinetics when all other influencing factors are controlled for, although controversy still exists. A current suggestion is that no woman who has previously been diagnosed with a potentially curable melanoma should become pregnant within the first 3 years after diagnosis because this period has the highest risk of recurrence. However, melanoma behaves in such an unpredictable m a n n e r that this is an arbitrary interval. In summary, we believe that ocular choroidal melanoma is a high-risk tumor with a significant potential for subsequent systemic spread, particularly to the liver but also to the products of conception should the woman become pregnant. All female patients with a history of this tumor should be apprised of the potential risk when they are contemplating pregnancy. REFERENCES
1. Anderson JF, Kent S, Machin CA. Maternal malignant melanoma with placental metastasis: a case report with literature review. Pediatr Pathol 1989;9:3542. 2. Dildy GA III, Moise KJJr, Carpenter RJJr, Klima T. Maternal malignancy metastatic to the products of conception: a review. Obstet Gynecol Surv 1989;14:536-40.
Central diabetes insipidus: A complication of ventriculoperitoneal shunt malfunction during pregnancy Lynn Goolsby, MD, and Frederick Harlass, MD El Paso, Texas During pregnancy ventriculoperitoneal shunts have reported complication rates of 30% to 60%. In this case a functionally occluded shunt resulted in prolonged increased intracranial pressure, pituitary stalk damage, and permanent central diabetes insipidus. This complication of ventriculoperitoneal shunt occlusion during pregnancy has not been previously reported. (AM J OBSTETGYNEOOL1996;174:1655-7.)
Key words: Ventriculoperitoneal shunt, diabetes insipidus, pregnancy
From theDepartment of Obstetricsand Gynecology, Texas Tech University Health Sciences Center.. Receivedfor publication May 8, 1995; revisedJuly 6, 1995; acceptedJuly 25, 1995. Reprint requests:Lynn Goolsby,MD, University ofArizona, Department of Obstetrics and Gynecology, 1501 N. Campbell, Tucson, AZ 85724, Copyright 9 1996 by Mosby-YearBook, Inc. 0002-9378/96 $5. O0 + 0 6/1/68222
Pregnancies complicated by ventriculoperitoneal shunts are u n c o m m o n but increasingly more frequent occurrences. Complications reported to date during pregnancy and the puerperium have included abdominal pain, shunt displacement, and functional shunt occlusion. Although p e r m a n e n t central diabetes insipidus is well documented as a posttraumatic complication of 1655
Key words: Ocular melanoma, placenta, pregnancy
We report a case of primary ocular choroidal melanoma metastasizing to the liver, skeleton, and, most important, placenta during pregnancy. Case r e p o r t The patient, a 31-year-old woman, underwent enucleation of the right eye in March 1993 for a primary choroidal melanoma. It was thought that the tumor had been thoroughly excised and there was no evidence of metastasis. She was lost to follow-up and was seen again approximately 1 year later, pregnant, with a gestational age of 36 weeks. In addition to the usual symptoms of From the Department of Medicine, University ofFlorida. Receivedfor publication August 10, 1995; revised September28, 1995; accepted October19, 1995. Reprint requests:Robert de W. Marsh, MB, ChB, Department of Medicine, University of Florida, 1600 S.W. Archer Road, Rm. R4-114, Gainesville, FL 32610-0277. Copyright 9 1996 by Mosby-YearBook, Inc. 0002-9378/96 $5.00+ 0 6/1/70000
pregnancy, she complained of right flank and sacroiliac pain, and subsequent evaluation showed multiple metastatic lesions in the liver. After confirmation of fetal lung maturity by amniocentesis, oxytocin (Pitocin) induction was initiated and the baby was delivered uneventfully. Gross examination of the placenta did not show any evidence of metastatic disease. However, on microscopic examination (Fig. 1), nests of epitheloid and spindle cells were seen in the intervillous space surrounding multiple stem and tertiary villae. Some of these contained finely dispersed black-to-brown pigment and stained positively with S-100 and HMB45. This was consistent with metastatic melanoma involving the placenta. Examination of the fetus, by both physical examination and abdominal ultrasonography, was unable to detect any evidence of fetal involvement. The mother herself was evaluated by computed tomogTaphic scans of the head, chest, abdomen, and pelvis, a s well as a bone scan. The only additional finding was widespread skeletal involvement. Potential therapeutic interventions were discussed with the
Fig. 1. Placental involvement of metastatic melanoma. 1654
Goolsby and Harlass
Volume 174, Number 5 Am J Obstet Gynecol
family, but unfortunately the mother died within 3 weeks of massive thrombotic disease of the inferior vena cava and hepatic veins with subsequent emboli to the lungs. Comment
A review of the literature does not reveal any previously reported cases of ocular choroidal melanoma metastasizing to the placenta or fetus. There are, however, a number of reports of cutaneous melanoma and other maternal malignancies with placental spread?' ~ Placental metastasis almost always occurs in the presence of widespread hematogenous dissemination of disease and usually portends a poor prognosis for the mother. Malign a n t melanoma is disproportionately represented in this group of individuals, with 58% of all cases reported representing malignant melanoma, 2 but with only 8% of all malignancies in pregnant women estimated to be the result of melanoma. Fortunately, clinically detectable transplacental spread to the fetus occurs less frequendy and does not always result in the establishment of overt disease, with only 25% of at-risk infants dying of the disease. This is probably due to failure of the malignant cells to cross the placenta and to implant successfully in fetal tissue, perhaps partially because of immunologic rejection. Conflicting opinions have been expressed concerning the influence of pregnancy on the behavior of mela-
noma.1. 2 Although increased hormonal levels during pregnancy theoretically have deleterious effects, the aggregate results from a n u m b e r of studies indicate that there is no net effect on tumor kinetics when all other influencing factors are controlled for, although controversy still exists. A current suggestion is that no woman who has previously been diagnosed with a potentially curable melanoma should become pregnant within the first 3 years after diagnosis because this period has the highest risk of recurrence. However, melanoma behaves in such an unpredictable m a n n e r that this is an arbitrary interval. In summary, we believe that ocular choroidal melanoma is a high-risk tumor with a significant potential for subsequent systemic spread, particularly to the liver but also to the products of conception should the woman become pregnant. All female patients with a history of this tumor should be apprised of the potential risk when they are contemplating pregnancy. REFERENCES
1. Anderson JF, Kent S, Machin CA. Maternal malignant melanoma with placental metastasis: a case report with literature review. Pediatr Pathol 1989;9:3542. 2. Dildy GA III, Moise KJJr, Carpenter RJJr, Klima T. Maternal malignancy metastatic to the products of conception: a review. Obstet Gynecol Surv 1989;14:536-40.
Central diabetes insipidus: A complication of ventriculoperitoneal shunt malfunction during pregnancy Lynn Goolsby, MD, and Frederick Harlass, MD El Paso, Texas During pregnancy ventriculoperitoneal shunts have reported complication rates of 30% to 60%. In this case a functionally occluded shunt resulted in prolonged increased intracranial pressure, pituitary stalk damage, and permanent central diabetes insipidus. This complication of ventriculoperitoneal shunt occlusion during pregnancy has not been previously reported. (AM J OBSTETGYNEOOL1996;174:1655-7.)
Key words: Ventriculoperitoneal shunt, diabetes insipidus, pregnancy
From theDepartment of Obstetricsand Gynecology, Texas Tech University Health Sciences Center.. Receivedfor publication May 8, 1995; revisedJuly 6, 1995; acceptedJuly 25, 1995. Reprint requests:Lynn Goolsby,MD, University ofArizona, Department of Obstetrics and Gynecology, 1501 N. Campbell, Tucson, AZ 85724, Copyright 9 1996 by Mosby-YearBook, Inc. 0002-9378/96 $5. O0 + 0 6/1/68222
Pregnancies complicated by ventriculoperitoneal shunts are u n c o m m o n but increasingly more frequent occurrences. Complications reported to date during pregnancy and the puerperium have included abdominal pain, shunt displacement, and functional shunt occlusion. Although p e r m a n e n t central diabetes insipidus is well documented as a posttraumatic complication of 1655