and its pigment-producing melanocytes. Melanomas should be suspected in pigmented lesions that show changes in contour, surface elevation, discoloration, bleeding, or ulceration, which should prompt biopsy (Richtig, 2017). They are most com in women of childbearing age.
In some population studies, melanoma is the most frequent malignancy complicating pregnancy (Andersson, 2015; Ban nister-Tyrrell, 2015). Still, the reported incidence ranges widely from 0.03 to 2.8 per 1000 live births (Eibye, 2013; Smith, 2003). One explanation is that many are treated as outpatients and thus are not entered into tumor registries. As noted earlier (p. 1192), malignant melanoma is one of the tumors that is known to metastasize to the placenta and fetus. Placental evaluation for metastases should be performed after delivery.
Staging is clinical. Stage I is a melanoma with no palpable lymph nodes; in stage II, lymph nodes are palpable; and in stage III, there are distant metastases. For patients with stage
I, tumor thickness is the single most important predictor of survival. he Clark classiication includes ive levels of involve ment by depth into the epidermis, dermis, and subcutaneous fat. he Breslow scale measures tumor thickness and size, in addition to depth of invasion.
Primary surgical treatment for melanoma is determined by the stage and includes wide local resection, sometimes with extensive regional lymph node dissection. Schwartz and associates (2003) recommend sentinel lymph node mapping and biopsy using 99mT c-sulfur colloid, which has a calculated fetal dose of 0.014 mSv or 0.014 mGy. Routine regional node dissection reportedly improves survival rates in nonpregnant patients with microscopic metastases (Cascinelli, 1998). For pregnant patients, an algorithm has been proposed that begins with resection of the primary tumor under local anesthesia but postpones sentinel lymph node biopsy until after delivery (Broer, 2012). lthough prophylactic chemotherapy or immunotherapy is usually avoided during pregnancy, it may be given if indicated by tumor stage and maternal prognosis. In most cases of distant metastatic melanoma, treatment is at best palliative. Currently, the role of estrogen receptor-� in melanoma progression is under investigation, and it may be a target for future therapeutic intervention (de Giorgi, 2011).
Stage-for-stage, survival is equivalent between pregnant and nonpregnant women (Driscoll, 2016; Johansson, 2014). In one study, half of pregnant women had stage III or IV lesions (de Haan, 2017). Therapeutic abortion does not improve maternal survival rates. Clinical stage is the strongest determinant of survival, and women with deep cutaneous invasion or regional node involvement have the worst prognosis. Approximately 60 percent of recurrences will manifest within 2 years, and 90 percent by 5 years. Thus, most recommend that pregnancy be avoided for 3 to 5 years after surgical resection. Interim contraception can include combination oral contraceptives, as they do not appear to have adverse cancer efects (Gandini, 2011). Related, subsequent pregnancies in women with localized melanoma do not lower cancer survival rates (Driscoll, 2009).