Chapter 31: Skin Cancer and Pregnancy

SUMMARY

• Melanoma is among the most commonly diagnosed cancers during pregnancy. Although the prognostic implications of pregnancy-associated melanoma have been debated, recent evidence suggests that there are no significant differences in maternal outcomes relative to nonpregnant women.

• Surgical management of melanoma during pregnancy concerning excision and sentinel lymph node biopsy aligns with the current standard of care in the general population. However, ultrasound surveillance of draining nodal basin(s) may be offered as an alternative to sentinel lymph node biopsy, especially during the first trimester.

• Few case reports and studies exist that consider the safety of treatment options for advanced disease in both melanoma and nonmelanoma skin cancer in pregnant patients. Thus, in this patient population, caution is advised when considering targeted therapies and immunotherapies.

DON’T FORGET

• Aside from areas of the skin that naturally expand and stretch during pregnancy, such as the abdomen and breasts, changing melanocytic nevi during pregnancy should warrant further examination by a dermatologist.

• To prevent delays in diagnosis and treatment, clinicians should evaluate any unusual or changing melanocytic nevi in pregnant women via dermoscopy and, if concerning, excise and biopsy the lesion as they would in nonpregnant patients.

CLINICAL PEARLS

• For surveillance and imaging, nonionizing radiation modalities such as magnetic resonance imaging and ultrasonography are preferred in pregnant patients with skin cancer because exposure to radiation from computed tomography, radiography, and positron emission tomography may lead to an increased risk of fetal carcinogenesis.

• Small amounts of infiltrative lidocaine and epinephrine are considered safe during pregnancy when performing local excisions of cancerous lesions of the skin.

PATIENT EDUCATION POINTS

• Most targeted therapies and immunotherapies for skin cancer have known teratogenic effects, suspected fetal toxicities, or are not well studied in their interaction with pregnancy.

• Therefore, when considering these novel therapies, pregnant patients with skin cancer must be warned appropriately, and ultimately their decision to use these drugs should be subject to a risk-benefit analysis between themselves and their care team.

• Pregnant patients with metastatic melanoma should be educated that placental metastases are exceedingly rare and that the odds of vertical transmission to the fetus are even lower.