**2. Definition**

Deciding on the role of pregnancy in the development of melanoma is important, as more women are planning a pregnancy from 30 to 40 years, and an increase in the number of melanoma diagnoses during fetal growth is expected [3, 4]. Currently, the term "melanoma associated with pregnancy" is used, implying the inclusion of all clinical observations of the diagnosis of melanoma during pregnancy and in the first 2 years after delivery [5].

### **2.1 Diagnosis prior to pregnancy**

Few studies have addressed the impact on prognosis when melanoma is diagnosed before a woman becomes pregnant, but based upon the available data, there does not appear to be an effect on prognosis. In a large Swedish retrospective cohort study [6], 966 women who had pregnancies after a diagnosis of a primary

**57**

*Melanoma and Pregnancy: Risks, Current, and Forecast DOI: http://dx.doi.org/10.5772/intechopen.86928*

**2.2 Diagnosis during pregnancy**

**2.3 Diagnosis postpartum**

**3. Classification**

frequent dermatology examinations during pregnancy [7].

melanoma were compared with 4567 women who did not become pregnant after diagnosis. After adjustment for Breslow depth, tumor site, Clark level, and age, pregnancy did not significantly affect survival (HR 0.58, 95% CI 0.32–1.05). For patients with a history of melanoma and multiple dysplastic nevi, we suggest more

Most of the multiple small controlled studies and large population-based cohort studies [6] do not show a negative influence of pregnancy on survival [2]. In a review of 10 case-control studies that included 185 women diagnosed with melanoma during pregnancy and 5348 women of the same childbearing age who were diagnosed with melanoma but were not pregnant, pregnancy did not have an impact on survival and did not increase the risk of a second melanoma [8]. The higher the parity and the younger the age of the mother at her first delivery, the lower the risk of melanoma. Thus, the authors concluded that there was no reason for physicians to recommend deferral of subsequent pregnancies in women who have been diagnosed with a stage I melanoma during a previous pregnancy [1]. A controversial study is a single-institution study that compared 41 women diagnosed with PAM with a control group of women of childbearing age who were not pregnant within 1 year of diagnosis [9]. PAM was defined as melanoma diagnosis either during pregnancy or within 1 year after delivery. After adjustment for stage, age, and location, the PAM group showed a five-, seven-, and ninefold increase in mortality, metastasis, and recurrence, respectively, when compared with controls.

Multiple large population-based cohort studies [3, 10] and one small controlled study have generally found no influence on prognosis when melanoma is diagnosed up to 5 years following delivery, except for one study that observed an enhanced risk of death from melanoma in the first year postpartum, which may be due to delayed diagnosis during pregnancy. A large retrospective English study that linked data from a national cancer registry and hospital discharge data evaluated patients diagnosed with melanoma up to 5 years postpartum [10]. There was a significant increased death rate in the first year after delivery (HR 1.92, 95% CI 1.32–2.79) but not in the four subsequent years postpartum. Another study found a lower incidence of melanoma diagnosed during pregnancy than expected compared with the first 6 months postpartum [2]. The spike in melanoma diagnosis and death in the

The eighth edition of the American Joint Committee on Cancer (AJCC) tumor, node, and metastasis (TNM) staging system is based upon an evaluation of the primary tumor, the regional lymph nodes and lymphatic drainage, and the presence or absence of distant metastases. The information from TNM staging is then combined to classify patients into AJCC prognostic stage groups. There are four major growth patterns of melanoma: lentigo maligna, nodular, superficial spreading, and acral lentiginous. In an observational study of close to 120,000 patients with melanoma, nodular melanoma was an independent risk factor for death, after controlling for thickness, ulceration, and stage [11]. Nevertheless, the eighth edition of the American Joint Committee on Cancer tumor, node, and metastasis staging system,

early postpartum period may be caused by a delay in diagnosis.

melanoma were compared with 4567 women who did not become pregnant after diagnosis. After adjustment for Breslow depth, tumor site, Clark level, and age, pregnancy did not significantly affect survival (HR 0.58, 95% CI 0.32–1.05). For patients with a history of melanoma and multiple dysplastic nevi, we suggest more frequent dermatology examinations during pregnancy [7].

## **2.2 Diagnosis during pregnancy**

*Cutaneous Melanoma*

the following:

**2. Definition**

prognosis of women diagnosed with melanoma during pregnancy. Initial concerns about pregnancy's impact on prognosis in women diagnosed with melanoma date back to case reports from the 1950s. These reports suggested that pregnancy might lead to transformation of nevi into melanomas, increase the growth rate of existing melanomas, and cause localized melanomas to metastasize [4]. Subsequently, multiple observations seemed to support the argument that melanoma is a hormonally responsive malignancy: changes in skin pigmentation during pregnancy, detection of hormone receptors on some melanomas using older technology, a higher incidence of melanoma after puberty, and relative immunosuppression during pregnancy. The management of women diagnosed with melanoma during pregnancy is likewise controversial, particularly concerning sentinel lymph node biopsy (SLNB) and decisions about the management of the patient with nodal or metastatic disease [5]. Multiple studies have looked at the relationship between pregnancy and cutaneous melanoma. Factors limiting the interpretation of the literature include

• Many of the case series prior to the 1980s did not account for the most important prognostic factors, such as depth of tumor or stage of disease. Subsequently, there have been a number of small case-control studies and large population-based cohort studies. While the case-control studies have the advantage of including important prognostic factors, the small numbers of patients included are an important limitation. Conversely, the larger cohort

• Some of the larger studies do not distinguish between diagnosis of melanoma during pregnancy and diagnosis during the postpartum period. Such studies refer to these patients as having pregnancy-associated melanoma (PAM). The definition of PAM varies in different studies and ranges from diagnosis during

• There is significant variability in the techniques and quality of the statistical analysis of the data between studies and in the presence of age-matched nonpregnant control groups, as well as a lack of consideration of important confounding factors, including but not limited to age, anatomic site of lesion, sun exposure or season at time of diagnosis, depth of the melanoma, the absence or presence of

Deciding on the role of pregnancy in the development of melanoma is important, as more women are planning a pregnancy from 30 to 40 years, and an increase in the number of melanoma diagnoses during fetal growth is expected [3, 4]. Currently, the term "melanoma associated with pregnancy" is used, implying the inclusion of all clinical observations of the diagnosis of melanoma during preg-

Few studies have addressed the impact on prognosis when melanoma is diagnosed before a woman becomes pregnant, but based upon the available data, there does not appear to be an effect on prognosis. In a large Swedish retrospective cohort study [6], 966 women who had pregnancies after a diagnosis of a primary

[2].

ulceration, and the presence as well as number of mitoses per mm2

studies lack complete data on staging and Breslow depth.

pregnancy to diagnosis up to 5 years after delivery [6].

nancy and in the first 2 years after delivery [5].

**2.1 Diagnosis prior to pregnancy**

**56**

Most of the multiple small controlled studies and large population-based cohort studies [6] do not show a negative influence of pregnancy on survival [2]. In a review of 10 case-control studies that included 185 women diagnosed with melanoma during pregnancy and 5348 women of the same childbearing age who were diagnosed with melanoma but were not pregnant, pregnancy did not have an impact on survival and did not increase the risk of a second melanoma [8]. The higher the parity and the younger the age of the mother at her first delivery, the lower the risk of melanoma. Thus, the authors concluded that there was no reason for physicians to recommend deferral of subsequent pregnancies in women who have been diagnosed with a stage I melanoma during a previous pregnancy [1]. A controversial study is a single-institution study that compared 41 women diagnosed with PAM with a control group of women of childbearing age who were not pregnant within 1 year of diagnosis [9]. PAM was defined as melanoma diagnosis either during pregnancy or within 1 year after delivery. After adjustment for stage, age, and location, the PAM group showed a five-, seven-, and ninefold increase in mortality, metastasis, and recurrence, respectively, when compared with controls.

### **2.3 Diagnosis postpartum**

Multiple large population-based cohort studies [3, 10] and one small controlled study have generally found no influence on prognosis when melanoma is diagnosed up to 5 years following delivery, except for one study that observed an enhanced risk of death from melanoma in the first year postpartum, which may be due to delayed diagnosis during pregnancy. A large retrospective English study that linked data from a national cancer registry and hospital discharge data evaluated patients diagnosed with melanoma up to 5 years postpartum [10]. There was a significant increased death rate in the first year after delivery (HR 1.92, 95% CI 1.32–2.79) but not in the four subsequent years postpartum. Another study found a lower incidence of melanoma diagnosed during pregnancy than expected compared with the first 6 months postpartum [2]. The spike in melanoma diagnosis and death in the early postpartum period may be caused by a delay in diagnosis.
