Education And Debate A difficult case

Management of metastatic melanoma during pregnancyCommentary: Pregnancy should not have affected treatment for melanomaCommentary: Self interest is not the sole legitimate basis for making decisionsCommentary: Management of the patient

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7134.848 (Published 14 March 1998) Cite this as: BMJ 1998;316:848

Management of metastatic melanoma during pregnancy

  1. S R D Johnston, consultant medical oncologista (stephen@icr.ac.uk),
  2. K Broadley, consultant in palliative medicineb,
  3. G Henson, consultant obstetriciand,
  4. C Fisher, consultant histopathologistc,
  5. M Henk, consultant clinical oncologista,
  6. M E Gore, head of skin and melanoma unita
  1. a Melanoma Unit, Royal Marsden Hospital, London SW3 6JJ
  2. b Palliative Care Unit, Royal Marsden Hospital, London SW3 6JJ
  3. c Department of Pathology, Royal Marsden Hospital
  4. d Department of Obstetrics and Gynaecology, Whittington Hospital, London N19 5NF
  5. University Hospital, Queen's Medical Centre, Nottingham NG7 2UH
  6. Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada
  7. a Melanoma Unit, Royal Marsden Hospital, London SW3 6JJ
  8. b Palliative Care Unit, Royal Marsden Hospital
  9. c Department of Pathology, Royal Marsden Hospital
  10. d Department of Obstetrics and Gynaecology, Whittington Hospital, London N19 5NF
  1. Correspondence to: Dr Johnston

    About 35% of women with melanoma are of child bearing age, and the coexistence of melanoma and pregnancy is increasing.1 Many doctors recommend that women wait two to three years after successful treatment for melanoma before becoming pregnant as most recurrences occur during this time. This advice is inadequate. Doctors need to inform these women about the considerable problems that may arise if relapse occurs while they are pregnant. We present our recent experience of this difficult situation: malignant melanoma within the maternal intervillous space, invading into the core of the villus. Immunostaining for S100 protein and HMB45 was positive, and staining for human chorionic gonadotropin was negative in the tumour cells.

    Case report

    A 41 year old woman presented with left axillary lymphadenopathy. A superficial spreading melanoma had been removed from her back two years previously. Radical lymph node dissection was performed. All nodes contained metastatic melanoma that stained positive for S100 and HMB45. There was evidence of extranodal tumour towards the deep resection margin, but her chest radiograph and liver ultrasonography were both normal. The woman had a professional career and had never been pregnant.

    The patient presented four months later with a short history of low back pain. Clinical examination showed no abnormalities and her neurological signs were normal. However, plain radiographs of the lumbar spine and computed tomography showed that the 8th thoracic vertebra had collapsed, associated with a soft tissue mass consistent with metastatic melanoma. The spinal cord was not affected.

    The patient reported that she was 12 weeks pregnant. Termination was discussed and the patient was counselled, but she and her partner were determined to continue with the pregnancy. Since she had no neurological signs of cord compression and her pain was intense, she was given a single palliative dose of radiotherapy to the affected …

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