Pregnancy Associated Melanoma: Diagnostic and Therapeutic Challenges

A rare clinical condition associated with numerous diagnostic and treatment challenges, pregnancy-associated melanoma (PAM), is defined as melanoma diagnosed either during pregnancy or within the first year postpartum. The physiological changes in pregnancy (hormonal changes and immune modulation), along with the normal changes in the pregnant woman's skin (skin color changes, etc.), may all hinder early detection of this disease and create concerns regarding the advancement of melanoma and the well-being of both the mother and her fetus. The purpose of this review article was to summarize the current literature on the incidence, biology, diagnostic methods and treatments of PAM, with an emphasis on comparison between the two forms of melanoma. More recent research indicates that pregnancy itself is not typically associated with decreased melanoma-specific survival rates. However, when worse results are reported, it appears that this may be more due to delays in initial diagnoses (diagnosis of cancer after delivery) or detection of cancer postpartum, as well as the increased number of stages of melanoma at which women were diagnosed at the time of their first evaluation compared to non-pregnant controls, rather than being a result of enhanced biologic aggressiveness in melanoma driven by pregnancy itself. The preclinical and translational models have suggested that pregnancy may influence melanoma biology through the mechanisms of hormonal signaling, immune system modulation and vascular remodeling; however, these mechanisms remain hypothesis-generating, and current clinical evidence does not indicate that changes in hormone levels during pregnancy negatively affect melanoma survival. Surgical excision is the mainstay of treatment and can be performed safely during pregnancy. In select patients, a sentinel lymph node biopsy may also be performed. Due to the risk of fetal harm, systemic therapy (targeted agents and/or immune checkpoint inhibitors) cannot be used for the treatment of PAM during pregnancy. Post-pregnancy treatment of PAM will follow standard melanoma treatment guidelines; however, the treatment options will need to take into consideration whether or not the patient is breastfeeding and if she desires to become pregnant again in the future. In summary, PAM will require a multidisciplinary, individualized approach to maximize oncologic outcomes while protecting the health of both the mother and her fetus. Awareness of this disease and timely diagnosis are critical to maximizing the prognosis.