Melanoma During Pregnancy
A Young Pregnant Woman
31 year old pregnant patient presented for routine skin check.
She had fair skin and was from an Anglo-Celtic heritage. She advised us she had no previous personal or family history with skin cancer. She was what we would consider as being an average risk for Melanoma.
Initial Diagnosis
A relatively innocuous mole was identified on her inner thigh. It is likely new, as the patient has no recollection of it being present before, and it had slightly darkened over the previous 2 months.
Immediate Treatment
This was removed - and proved to be a Melanoma-In-Situ.
This was then followed by a wide-area excision.
Melanoma Watch
The woman was placed on a 3 monthly review for the first 2 years, and then 6 monthly due to the higher risk of new melanomas in the first 2 years after diagnosis. She was also given detailed advice on solar protective strategies.
Over the following year, several new or changing moles were removed - all proving to be Dysplastic (pre-cancerous). None had overt evidence of being of specific concern.
A New Melanoma Is Found
A year and 4 months after the first Melanoma diagnosis - a new mole on the patient’s back - also having no clear evidence of melanoma - was excised and found to be Melanoma-In-Situ. Once again, a wide-area excision was performed, and 3 monthly reviews extended for another 2 years.
Several further excisions were performed in the 12 months after - all again proving to be Dysplastic (pre-cancerous).
A Second Pregnancy More Melanomas
A year later she fell pregnant with her second child and presented for a routine skin check.
A new lesion - having no clear evidence of melanoma - was removed from her right groin. This proved to be her third Melanoma in 3 years and proved again to be Melanoma-In-Situ. Wide-area local excision was performed which healed well.
Subsequent to this the patient underwent Baseline Digital Imaging to provide a detailed clinical record of what is/is not on her skin and will likely assist in early identification of changing/new moles so targeted excisions can be performed to intervene before Melanoma actually develops.
Early Melanoma Detection
This case demonstrates how Melanoma can occur in normal looking moles, and that a history of recent change and or new moles appearing can be of great importance to direct early treatment, and that regular skin checks can be critical to long-term outcomes. It makes the routine use of digital sequential monitoring strongly advisable for medium-high risk individuals, as there is no other proven method to find such ‘featureless Melanomas’ in their earlier phases where intervention leads to better outcomes.
It also raises the question whether to advise this technology be used in otherwise healthy individuals who are seen to be at only average risk, as was the case with this patient when she first presented.
Each of these Melanomas were identified before any spread. The best option is to intervene before a lesion becomes a Melanoma, and definitely before it becomes invasive. The digital sequential monitoring is the most accurate way, having been proven to double the rate of melanoma diagnosis and halve the number of excisions required.
Melanoma in Pregnancy
Melanoma is more likely in pregnancy, thought to be as a result of high concentrations of both growth factors and female hormones - which may initiate change in existing moles and promote the appearance and change in new moles, or Melanomas.
In my experience after 17 years in practise, each pregnancy adds approximately 3-5 years to a mother’s skin cancer age.
Skin checks are ideally performed on an annual basis utilising digital baseline imaging (or more frequently if medically recommended) on women who are trying to get pregnant, and then repeated at the time their pregnancy is confirmed, and again in the 3rd Trimester of their pregnancy, and at 6 and 12 months after delivery. The patient can return to their routine skin cancer imaging interval at this point.
It is theoretically possible - and has anecdotally been noted - for invasive Melanoma that is diagnosed in pregnancy to spread to the placenta, and thus may spread to the unborn child. This is an exceedingly rare event, but it is advised that the placentas of all pregnant women diagnosed with invasive Melanoma have their placentas sent for analysis to ensure deposits of metastatic Melanoma are not present.
