Management Of Melanoma During Pregnancy

Introduction

Understanding melanoma

Melanoma is a form of skin cancer caused by melanocytes. More specifically, melanoma results from the uncontrolled growth of melanocytes, which spread abnormally into surrounding tissues. Although this is not the most common type of skin cancer, melanoma is the most dangerous since most skin cancer deaths are caused by melanoma.

What are melanocytes?

Melanocytes are cells present in the skin and hair follicles. This refers to the cells that produce and synthesise melanin, the natural substance that pigments the skin, hair and iris.

Impact of pregnancy on melanoma

According to a recent study, malignant melanoma is the most frequently reported malignant tumour during pregnancy.¹ In addition, malignant melanoma is one of the most common malignancies in young females assigned at birth (FAAB),² and approximately one-third of all FAAB diagnosed are of reproductive age.³

Diagnosis and staging

Recognising melanoma signs and symptoms

The "ABCDE" rule explains the character of early melanomas.⁴ These characteristics include:

Asymmetry

The shape of one part is different from the other.

Border- irregular

The edges are often ragged, notched, or blurred outline. The pigment can be spread into the surrounding skin.

Colour- uneven 

Shades of black, brown, and tan may be present. White, grey, red, pink and blue areas may also be present.

Diameter

There is a change in size, usually an increase. Melanoma can be small, but most are larger than 6 millimetres wide (about 1/4 inch wide).

Evolution

The mole has changed over the last couple of weeks or months.

Melanoma is an oncological disorder that evolves asymptomatically over long periods of time. However, bleeding of a mole, oedema and redness of the skin near a nevus accompanied by itching are some of the frequent symptoms encountered during the progression of the disease.

Diagnostic tests for melanoma

A physical examination allows your physician to detect any signs of melanoma. A skin exam is frequently the first step in a physical exam. In the course of a skin examination, your doctor will check the entire surface of your skin and look for moles or abnormal areas. 

During a physical examination, your doctor may also check if the lymph nodes are enlarged by feeling your neck, groin or under your arms.

Dermoscopy

Dermoscopy makes it possible to see the areas of the skin more clearly. It also allows the physician to look at structures, such as blood vessels, that cannot be seen by looking only at the skin. It uses a tool with a special light and a magnifying glass to view the skin.

Skin biopsy

During a skin biopsy, the physician removes tissue or cells from the skin so that they can be tested in a laboratory. A report from the pathologist will confirm if the sample has cancer cells or not. The use of this biopsy type often depends on the appearance of growth and how large it is.

Excisional biopsy

Excisional biopsy is a type of surgical biopsy that eliminates all growth with the help of a scalpel (knife). An excisional biopsy is the best kind of biopsy for making an appropriate diagnosis of melanoma skin cancer.

Punch Biopsy

Punch Biopsy removes some part of the growth using a sharp tool called a punch. It can be done when the growth is of a substantial size. With the punch biopsy, the physician tries to remove most of the abnormal area of growth, including some of the edge. At times, a punch is large enough to eliminate all growth.

Shaving biopsy

Shaving biopsies cut a growth on the skin using a flexible razor blade or scalpel. It is sometimes used as long as the physician is able to remove enough tissue.

Staging the melanoma

Staging classifies cancer based on the amount of cancer in the body and its location at the time of first diagnosis. This is commonly referred to as the extent of cancer. Test data are used to determine the size (thickness) of the tumour, which areas of the skin have cancer and if the cancer has spread from where it started and where it has spread.

The most common staging system for melanoma is TNM. For melanoma, skin cancer consists of five stages: stage 0 is followed by stages 1 to 4. Generally, the higher the number of stages, the more the cancer has spread. 

• During the description of the phase, doctors often use the words early stage, locoregional or metastatic
• In the early stages, cancer is present only in the skin where it began and did not spread to other parts of the body (stage 0 - 2)
• Locoregion means that cancer has spread to nearby lymph nodes, or to nearby areas of skin or lymph vessels (stage 3)
• Metastatic means that cancer has spread to other areas of the body (distant metastases), such as the lungs or liver (stage 4)

Surveys to determine the extent of malignant skin melanoma (clinical stage)

• The objective exam
• Radiological examination
  • Chest X-ray
  • CT scan to mediastinum
  • Ultrasonographic examination of the organs of the abdominal cavity
  • Radiograph of the bones

Treatment considerations

Multidisciplinary approach to care

Multidisciplinary care of patients with cutaneous melanoma involving dermatologists, pathologists, genetic counsellors, social workers, radiation oncology, medical oncology, gynaecologists (for pregnant women) and patient's general practitioner is recommended for optimising the available care resources for management. Multidisciplinary examination of tumours is recommended in accordance with the National Comprehensive Cancer Network.⁵

Individualised treatment plans

Depending on the stage of cancer, dissemination, as well as other patient-related factors (for example, other associated diseases), the treatment plan is individualized to achieve the best therapeutic response with the least side effects. This means that one or more treatment methods can be chosen and used simultaneously.

Timing of treatment

In cases of early onset, early diagnosis can improve the chances of survival with rapid surgery. 

Evidence suggests a more favourable tumour thickness and improved survival in patients seen within two weeks of discovery of a pigmented lesion, noting that the benefit is maximized when coupled with rapid surgical management. 

Informal guidelines based on hypotheses and expert opinion recommend treatment within four to six weeks; while there is also evidence to suggest that treatment within two weeks may improve survival.⁶

Benefits and risks of treatment options⁷

Surgery

Surgical removal of the tumour is the primary treatment for all stages of melanoma. Broad local excision is used to remove melanoma and a portion of the surrounding normal tissue. Skin grafting (removing the skin from another part of the body to replace the removed skin) can be performed to cover the wound.

Surgery to eliminate cancer that has spread to lymph nodes, lungs, gastrointestinal tract, bones, or brain helps improve a patient's quality of life by controlling symptoms.

Radiation therapy

Radiotherapy is a cancer treatment that uses high-energy X-rays or other forms of radiation to kill cancer cells or prevent them from growing. External radiation therapy uses a machine outside the body to deliver radiation therapy to the area of the body affected by cancer. External radiation therapy is used to treat melanoma and for symptom relief.

Systemic therapy

Chemotherapy is a cancer treatment that uses drugs to stop cancer cells from growing, either by killing them or by preventing them from splitting. When chemotherapy is administered orally or injected into a vein or muscle, medications enter the bloodstream (systemic chemotherapy).

Targeted therapy

Targeted therapy is a type of treatment that uses medications or other substances to detect and attack specific cancer cells. Targeted therapies are usually less harmful to normal cells than chemotherapy or radiotherapy.

Immunotherapy

Immunotherapy is a treatment that uses the patient's immune system for cancer control. Substances manufactured by the body or in the laboratory are used to stimulate, direct, or restore the body's natural defences against cancer. It is a form of biological therapy.

Side effects of cancer therapy

Treatments for cancer have the potential to cause side effects. Side effects are problems that happen when the treatment involves healthy tissues or organs. 

Examples of side effects:

• Anemia
• Appetite loss
• Bleeding and bruising (Thrombocytopenia)
• Constipation/Diarrhea
• Oedema (Swelling)
• Fatigue
• Fertility issues 
• Hair boss 
• Infection and neutropenia
• Lymphedema
• Memory or focus issues
• Sickness and vomiting
• Nerve problems (Peripheral neuropathy)
• Pain
• Skin and fingernail changes
• Sleep problems 
• Urinary and bladder problems

Side effects vary from person to person, even for those receiving the same type of cancer treatment.

Follow-up tests

Follow-up tests may be needed.

Some of the tests that have been done to diagnose cancer or to discover the stage of cancer can be repeated. Decisions regarding whether treatment should continue, change or stop can be based on the results of these tests. Also, some tests will continue to be performed from time to time after treatment is completed. The results of these tests may show whether something has changed or the cancer has returned.

Pregnancy monitoring and management

Regular prenatal care

Prenatal care is of particular importance for high-risk pregnant women. These factors can increase the risk of problems while pregnant:

• Very young or above 35
• Overweight or underweight
• Trouble with previous pregnancies
• Pregnancies with twins, triplets, etc.
• Current or previous health problems, such as high blood pressure, diabetes, cancer, HIV and auto-immune diseases

If your pregnancy is considered high-risk, you should see your doctor more often to avoid further complications during pregnancy and labour. 

Collaboration between obstetricians and oncologists

Cancer while pregnant is rare. Cancer itself rarely impacts the unborn baby. When this occurs, cancer during pregnancy may be more difficult to diagnose and treat. Most of the diagnostic modalities currently used do not harm the unborn baby.⁸ Treatments can affect the baby, so every stage of your medical care will be performed with attention.

Your oncology physicians and obstetricians will explore and compare the best treatment options for you and any possible risks. The stage of pregnancy, as well as the type, size and stage of cancer, are important. Your doctors will also talk to you about your preferences when you decide on cancer treatment. During all treatments, they will monitor you closely to ensure that the baby is in good health.

Foetal monitoring during treatment

The possible teratogenic effect of cancer treatment during pregnancy depends on the stage of development of the exposed foetus.⁸

About 10-20% of babies exposed to chemotherapy during the first trimester exhibit major malformations.

Malignant melanoma is the most common metastasizing tumour in the placenta or foetus. For this reason, close monitoring of foetal well-being is necessary.

The improvement of neonatal care will facilitate the decision of induced premature births (even at 30-32 weeks), thereby limiting the duration from diagnosis to proper management of the malignant process.

Avoiding harmful procedures

There are times when doctors recommend delaying or avoiding certain treatments during pregnancy. For example:

In the first three months of pregnancy, some cancer treatments are most likely to harm the foetus. As a result, your physicians may recommend deferring treatment until the second or third trimester.

Certain treatments may be harmful to the baby at any time during pregnancy. Physicians try not to use these treatments until the baby is born. For example, radiotherapy is a powerful treatment that uses high-energy X-rays to destroy cancerous cells. Depending on the radiation dose and the region of the body that needs to be treated, there may be risks to the unborn baby during pregnancy.

When doctors find cancer later in pregnancy, they may recommend to begin treatment after the birth of the baby.

Psychological and emotional support

Coping with diagnosis and treatment

Receiving a cancer diagnosis or beginning cancer treatment during pregnancy can be very stressful and overwhelming. Throughout this experience, it is important to let your healthcare team know how you are feeling so that they can help you find the support you need.

Supportive resources for patients and families

It may be useful to establish a solid support network for patients and caregivers going through a diagnosis like melanoma. This can be an in-person or online support group for others who have or have had cancer while pregnant. 

Some helpful links are as follows:

• https://melanoma.org
• http://cancerinpregnancy.org
• https://hopefortwo.org
• https://cancerandpregnancy.com

Addressing concerns about fetal Health

The best way to have a healthy child is to take care of yourself during your pregnancy. Consider cancer therapy during pregnancy if your doctor recommends it. Also, take time for yourself, accept others' help, rest and eat when you can between treatments and during them.

Long-term follow-up and prognosis

Post-treatment surveillance

All patients diagnosed with melanoma at any stage of the disease remain in a dermatological follow-up program. If the disease is advanced, they should conduct regular checks with the oncologist and surgeon.

In addition to these regular assessments, self-examination is very important. Self-examination must be performed monthly. As a result, each patient will be able to detect potential new lesions on the body. 

Monitoring for recurrence or metastasis

In general, the dermatological evaluation is carried out every 3-6 months during the first 2 years after diagnosis and every 3-12 months within the next 3 years. After 5 years of diagnosis, these assessments may be performed annually. Of course, a monthly self-assessment is recommended, as is the case for healthy patients.

Prognosis and survival rates

American Cancer Society explains that a relative survival rate compares individuals with the same type and stage of cancer to the population as a whole.⁹

Localized: There is no evidence of cancer spreading beyond the skin where it began.

Regional: Cancer has spread beyond the skin and into nearby structures or lymph nodes.

Distant: Cancer has spread to distant parts of the body, like the lungs, liver or brain

Planning future pregnancies

Often, pregnancy after cancer treatment is harmless for both mother and child. However, some women may be told to wait a certain amount of time before trying to have a baby. Time depends on many factors:

• The type of cancer and stage
• Type of treatment
• A woman’s age

For some survivors, it may be necessary to stop certain medications in order to become pregnant. However, stopping certain medications increases the risk of cancer coming back. People planning to have children must talk about the risk they are prepared to accept.

Summary

Melanoma is a form of skin cancer that develops when the melanocytes begin to grow out of control. It progresses asymptomatically over long periods of time. Any changes to the thickness, colour or shape of the tumour require a clinical dermatological examination as soon as possible. Bleeding of a mole, oedema and redness of the skin in the vicinity of a nevus accompanied by itching are some of the frequent symptoms encountered during the progression of the disease.

Melanoma is the most dangerous type of skin cancer because it is much more likely to spread to other parts of the body if it is not detected and treated in time. Most types of skin cancer can be cured if treated prior to their spread, as the survival rate is higher in these cases. The sooner the skin cancer is discovered and removed, the stronger the chances of recovery.

Cancer during pregnancy occurs rarely. Cancer itself often does not affect the unborn baby. Yet when this does happen, cancer while pregnant can be more difficult to diagnose and treat. 

Any change in tumour thickness, colour or shape of pigmented nevi requires a clinical dermatological examination as soon as possible.