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Pelczar P, Kosteczko P, Wieczorek E, Kwieciński M, Kozłowska A, Gil-Kulik P. Melanoma in Pregnancy-Diagnosis, Treatment, and Consequences for Fetal Development and the Maintenance of Pregnancy. Cancers (Basel) 2024; 16:2173. [PMID: 38927879 PMCID: PMC11202133 DOI: 10.3390/cancers16122173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Cutaneous malignant melanoma is one of the most common neoplasms among pregnancy-associated cancers (PACs). Risk factors include excessive exposure to ultraviolet radiation, the presence of benign and dysplastic nevi, and a patient or family history of melanoma. Self-examination and careful inspection of nevi are crucial, especially in the context of their progression over time. Physiological changes that occur during pregnancy, such as the darkening and enlargement of the nevi, delay the diagnosis of CMM. In the fetus, metastases are very rare, and if they do occur, they concern the placenta or fetal tissues. The choice of treatment is influenced by the cancer stage, symptoms, the time of termination of pregnancy, and the patient's decision. Essential procedures which are safe for the fetus are diagnostic biopsy, ultrasound, and the therapeutic excision of the lesion and the affected lymph nodes. Other imaging methods can be used with a safe radiation dose limit of 100 mGy. Immunotherapy and targeted treatments must be carefully considered, because of their possible adverse effects on the fetus. An interdisciplinary approach to the problem of melanoma during pregnancy is necessary, involving doctors of various specialties.
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Affiliation(s)
- Patrycja Pelczar
- Student Scientific Society of Clinical Genetics, Medical University of Lublin, 11 Radziwillowska Str., 20-080 Lublin, Poland; (P.P.); (P.K.); (E.W.); (M.K.)
| | - Pola Kosteczko
- Student Scientific Society of Clinical Genetics, Medical University of Lublin, 11 Radziwillowska Str., 20-080 Lublin, Poland; (P.P.); (P.K.); (E.W.); (M.K.)
| | - Ewelina Wieczorek
- Student Scientific Society of Clinical Genetics, Medical University of Lublin, 11 Radziwillowska Str., 20-080 Lublin, Poland; (P.P.); (P.K.); (E.W.); (M.K.)
| | - Maciej Kwieciński
- Student Scientific Society of Clinical Genetics, Medical University of Lublin, 11 Radziwillowska Str., 20-080 Lublin, Poland; (P.P.); (P.K.); (E.W.); (M.K.)
| | - Aleksandra Kozłowska
- Department of Radiotherapy, Medical University of Lublin, 13 Radziwillowska Str., 20-080 Lublin, Poland;
| | - Paulina Gil-Kulik
- Department of Clinical Genetics, Medical University of Lublin, 11 Radziwillowska Str., 20-080 Lublin, Poland
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Linkeviciute A, Canario R, Peccatori FA, Dierickx K. Caring for Pregnant Patients with Cancer: A Framework for Ethical and Patient-Centred Care. Cancers (Basel) 2024; 16:455. [PMID: 38275896 PMCID: PMC10813952 DOI: 10.3390/cancers16020455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/13/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
(1) Background: Caring for pregnant cancer patients is clinically and ethically complex. There is no structured ethical guidance for healthcare professionals caring for these patients. (2) Objective: This concept paper proposes a theoretically grounded framework to support ethical and patient-centred care of pregnant cancer patients. (3) Methodological approach: The framework development was based on ethical models applicable to cancer care during pregnancy-namely principle-based approaches (biomedical ethics principles developed by Beauchamp and Childress and the European principles in bioethics and biolaw) and relational, patient-focused approaches (relational ethics, ethics of care and medical maternalism)-and informed by a systematic review of clinical practice guidelines. (4) Results: Five foundational discussion themes, summarising the key ethical considerations that should be taken into account by healthcare professionals while discussing treatment and care options with these patients, were identified. This was further developed into a comprehensive ethics checklist that can be used during clinical appointments and highlights the need for a holistic view to patient treatment, care and counselling while providing ethical, patient-centric care. (5) Conclusion: The proposed framework was further operationalised into an ethics checklist for healthcare professionals that aims to help them anticipate and address ethical concerns that may arise when attending to pregnant cancer patients. Further studies exploring clinicians' attitudes towards cancer treatment in the course of pregnancy and patient experiences when diagnosed with cancer while pregnant and wider stakeholder engagement are needed to inform the development of further ethical, patient-centred guidance.
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Affiliation(s)
- Alma Linkeviciute
- Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Rita Canario
- Cancer Metastasis i3S-Institute for Research & Innovation in Health, R. Alfredo Allen 208, 4200-135 Porto, Portugal;
- Research Centre, Portuguese Oncology Institute of Porto, 4200-072 Porto, Portugal
- ICBAS—School of Medicine and Biomedical Sciences, University of Porto, R. Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Fedro Alessandro Peccatori
- Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Kris Dierickx
- Centre for Biomedical Ethics and Law, KU Leuven, 3000 Leuven, Belgium;
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Kim AE, Nelson A, Stimpert K, Flyckt RL, Thirumavalavan N, Baker KC, Weinmann SC, Hoimes CJ. Minding the Bathwater: Fertility and Reproductive Toxicity in the Age of Immuno-Oncology. JCO Oncol Pract 2022; 18:815-822. [PMID: 36174117 PMCID: PMC10166412 DOI: 10.1200/op.22.00469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/29/2022] [Indexed: 01/05/2023] Open
Abstract
Immune checkpoint inhibition has resulted in significant efficacy across many cancer types, including melanoma. Melanoma is the second most common cancer among those of reproductive age, yet the reproductive toxicities of adjuvant and first-line immunotherapy are largely unknown.The normal innate and adaptive immune systems play a vital role in reproductive organ homeostasis of men and women and are essential for implantation, fertility, and a successful pregnancy. The programmed cell death-1 receptor/programmed cell death receptor ligand-1 (PD-1/PD-L1) pathway is essential in several aspects of fertility and pregnancy. Recent studies have largely focused on the role of the PD-1/PD-L1 pathway in fetomaternal tolerance, highlighting the importance of intact immune regulation in promoting a successful pregnancy.In this review, we describe a case of a reproductive-aged female with stage IIIC melanoma who sought guidance on family planning after pembrolizumab therapy. We discuss the known fertility-related toxicities of immune checkpoint inhibitors, the potential targets for reproductive toxicity in males and nonpregnant females, and the implications of anti-PD-1 therapy in relation to fetomaternal tolerance. Informed decision making will benefit from data and consensus.
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Affiliation(s)
- Anne E. Kim
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Ariel Nelson
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
- Department of Medicine, Division of Hematology and Oncology, The Medical College of Wisconsin, Milwaukee, WI
| | - Kyle Stimpert
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
- VA Northeast Ohio Healthcare System, Cleveland, OH
| | | | - Nannan Thirumavalavan
- Department of Urology, University Hospitals, Case Western Reserve University, Cleveland, OH
| | | | - Sophia C. Weinmann
- Division of Rheumatology and Immunology, Duke University, Durham, NC
- Center for Cancer Immunotherapy, Duke University, Durham, NC
| | - Christopher J. Hoimes
- Center for Cancer Immunotherapy, Duke University, Durham, NC
- Duke Cancer Institute, Duke University, Durham, NC
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Martínez-Campayo N, Paradela de la Morena S, Pértega-Díaz S, Iglesias Pena L, Vihinen P, Mattila K, Lens MB, Tejera-Vaquerizo A, Fonseca E. Survival of Women Previously Diagnosed of Melanoma with Subsequent Pregnancy: A Systematic Review and Meta-Analysis and a Single-Center Experience. J Clin Med 2021; 11:jcm11010083. [PMID: 35011822 PMCID: PMC8745217 DOI: 10.3390/jcm11010083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/13/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
Melanoma incidence has increased over the last few decades. How the prognosis of a previously diagnosed melanoma may be affected by a woman’s subsequent pregnancy has been debated in the literature since the 1950s, and the outcomes are essential to women who are melanoma survivors in their childbearing years. The main objective of this systematic review is to improve the understanding of whether the course of melanoma in a woman may be altered by a subsequent pregnancy and to help clinicians’ diagnosis. Eligible studies for the systematic review were clinical trials, observational cohort studies and case-control studies that compared prognosis outcomes for non-pregnant patients with melanoma, or pregnant before melanoma diagnosis, versus pregnant patients after a diagnosis of melanoma. The search strategy yielded 1101 articles, of which 4 met the inclusion criteria for the systematic review. All the studies were retrospective non-randomised cohorts with patients with melanomas diagnosed before pregnancy. According to our findings, a subsequent pregnancy was not a significant influence on the outcome of a previous melanoma. However, given the small number of identified studies and the heterogeneous data included, it is recommended to approach these patients with caution, and counselling should be given by known prognostic factors. We also reviewed the medical records of 84 patients of childbearing age (35.8 ± 6.3 years, range 21–45 years) who were diagnosed with cutaneous invasive melanoma in our hospital between 2008 and 2018 (N = 724). Of these, 11 (13.1%) had a pregnancy after melanoma diagnosis (age at pregnancy: 35.6 ± 6.3 years). No statistical differences in outcome were detected.
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Affiliation(s)
- Nieves Martínez-Campayo
- Department of Dermatology, University Hospital of A Coruña, 15006 Corunna, Spain; (S.P.d.l.M.); (L.I.P.); (E.F.)
- Correspondence:
| | - Sabela Paradela de la Morena
- Department of Dermatology, University Hospital of A Coruña, 15006 Corunna, Spain; (S.P.d.l.M.); (L.I.P.); (E.F.)
| | - Sonia Pértega-Díaz
- Department of Research, University Hospital of A Coruña, 15006 Corunna, Spain;
| | - Luisa Iglesias Pena
- Department of Dermatology, University Hospital of A Coruña, 15006 Corunna, Spain; (S.P.d.l.M.); (L.I.P.); (E.F.)
| | - Pia Vihinen
- FICAN West Cancer Centre and Department of Oncology, Turku University Hospital and University of Turku, 20521 Turku, Finland; (P.V.); (K.M.)
| | - Kalle Mattila
- FICAN West Cancer Centre and Department of Oncology, Turku University Hospital and University of Turku, 20521 Turku, Finland; (P.V.); (K.M.)
| | - Marko B. Lens
- Genetic Epidemiology Division, Cancer Research UK, St. James’s University Hospital, Beckett St., Leeds LS9 7TF, UK;
| | - Antonio Tejera-Vaquerizo
- Department of Dermatology, Dermatologic Institute GlobalDerm, Palma del Río, 14700 Cordova, Spain;
- Unit of Cutaneous Oncology, San Juan de Dios Hospital, 14012 Cordova, Spain
| | - Eduardo Fonseca
- Department of Dermatology, University Hospital of A Coruña, 15006 Corunna, Spain; (S.P.d.l.M.); (L.I.P.); (E.F.)
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Romanelli MR, Mansour A, Topaz A, Olla D, Neumeister MW. Melanoma in Pregnancy and Pediatrics. Clin Plast Surg 2021; 48:699-705. [PMID: 34503730 DOI: 10.1016/j.cps.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Rare variants of melanoma include melanoma in pregnancy and pediatric melanoma. Because of their low incidence, treatment recommendations are based on standards of treatment for cutaneous melanoma; however, each of these forms requires specific considerations during diagnosis, staging, and treatment.
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Affiliation(s)
- Michael R Romanelli
- Institute for Plastic Surgery, Southern Illinois University, 747 North Rutledge Street #3, Springfield, IL 62702, USA
| | - Alaa Mansour
- Southern Illinois University School of Medicine, 747 North Rutledge Street #3, Springfield, IL 62702, USA
| | - Allyne Topaz
- Institute for Plastic Surgery, Southern Illinois University, 747 North Rutledge Street #3, Springfield, IL 62702, USA
| | - Danielle Olla
- Institute for Plastic Surgery, Southern Illinois University, 747 North Rutledge Street #3, Springfield, IL 62702, USA.
| | - Michael W Neumeister
- Department of Surgery, Institute for Plastic Surgery, Southern Illinois University, 747 North Rutledge Street #3, Springfield, IL 62702, USA
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Hassel JC, Livingstone E, Allam JP, Behre HM, Bojunga J, Klein HH, Landsberg J, Nawroth F, Schüring A, Susok L, Thoms KM, Kiesel L, Berking C. Fertility preservation and management of pregnancy in melanoma patients requiring systemic therapy. ESMO Open 2021; 6:100248. [PMID: 34438241 PMCID: PMC8390524 DOI: 10.1016/j.esmoop.2021.100248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 01/09/2023] Open
Abstract
Melanoma is one of the most common cancers in adolescents and adults at fertile age, especially in women. With novel and more effective systemic therapies that began to profoundly change the dismal outcome of melanoma by prolonging overall survival, the wish for fertility preservation or even parenthood has to be considered for a growing portion of melanoma patients-from the patients' as well as from the physicians' perspective. The dual blockade of the mitogen-activated protein kinase pathway by B-Raf proto-oncogene serine/threonine kinase and mitogen-activated protein kinase inhibitors and the immune checkpoint inhibition by anti-programmed cell death protein 1 and anti-cytotoxic T-lymphocyte-associated protein-4 monoclonal antibodies constitute the current standard systemic approaches to combat locally advanced or metastatic melanoma. Here, the preclinical data and clinical evidence of these systemic therapies are reviewed in terms of their potential gonadotoxicity, teratogenicity, embryotoxicity and fetotoxicity. Recommendations for routine fertility and contraception counseling of melanoma patients at fertile age are provided in line with interdisciplinary recommendations for the diagnostic work-up of these patients and for fertility-protective measures. Differentiated recommendations for the systemic therapy in both the adjuvant and the advanced, metastatic treatment situation are given. In addition, the challenges of pregnancy during systemic melanoma therapy are discussed.
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Affiliation(s)
- J C Hassel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - E Livingstone
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - J P Allam
- Department of Andrology, University Hospital Bonn, Bonn, Germany
| | - H M Behre
- Center for Reproductive Medicine and Andrology, University Hospital Halle (Saale), Halle (Saale), Germany
| | - J Bojunga
- Department of Endocrinology, Diabetology and Nutrition Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - H H Klein
- Department of Internal Medicine, Endocrinology & Diabetology & Gastroenterology and Hepatology, BG University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - J Landsberg
- Department of Dermatology and Allergy, University Hospital Bonn, Bonn, Germany
| | - F Nawroth
- Center for Infertility, Prenatal Medicine, Endocrinology and Osteology, Amedes Medical Center MVZ Hamburg, Hamburg, Germany
| | - A Schüring
- Fertility Center MVZ KITZ Regensburg, Regensburg, Germany
| | - L Susok
- Department of Dermatology, University Hospital Bochum, Bochum, Germany
| | - K M Thoms
- Department of Dermatology, Venereology and Allergy, University Medical Center Goettingen, Goettingen, Germany
| | - L Kiesel
- Department of Gynecology and Obstetrics, University Hospital Münster, Münster, Germany
| | - C Berking
- Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen EMN, Deutsches Zentrum Immuntherapie (DZI), Erlangen, Germany.
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7
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Li JN, Nijhawan RI, Srivastava D. Cutaneous Surgery in Patients Who Are Pregnant or Breastfeeding. Dermatol Clin 2019; 37:307-317. [PMID: 31084725 DOI: 10.1016/j.det.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Dermatologic surgery in pregnant/postpartum patients requires deliberate consideration. Although surgery can be safely performed during any trimester, the second trimester and immediate postpartum period is optimal. Surgery should not be delayed for melanoma/high-risk skin cancers. Perioperative positioning, analgesic, antiseptic, and antibiotic selection should be deliberate to avoid risk to the patient/fetus/infant. The left lateral tilt position reduces aortocaval compression syndrome. Lidocaine and epinephrine can be used safely. Alcohol and chlorhexidine are considered safe. Antibiotics commonly used in skin surgery are safe in pregnancy and lactation. Acetaminophen is first line for pain management. Nonsteroidal antiinflammatory drugs should be avoided.
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Affiliation(s)
- Jeffrey N Li
- Department of Dermatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, 5939 Harry Hines Boulevard, Professional Office Building 2, Suite 400, Dallas, TX 75390, USA
| | - Divya Srivastava
- Department of Dermatology, University of Texas Southwestern Medical Center, 5939 Harry Hines Boulevard, Professional Office Building 2, Suite 400, Dallas, TX 75390, USA.
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