Case report

Rapidly progressing malignant melanoma influenced by

pregnancy

Sung Hwan Youn, MD, Young Wook Lee, MD, Na Reu Seung, MD, Eun Ju Park, MD,Hee Jin Cho, MD, Kwang Ho Kim, MD, and Kwang Joong Kim, MD

Department of Dermatology,

College of Medicine, Hallym University,

Hallym Sacred Heart Hospital,

Gyeonggi-do, and

ChunCheon Sacred Heart Hospital,

ChunCheon-si, Korea

Correspondence

Kwang Joong Kim, MD

Department of Dermatology,

College of Medicine, Hallym University,

896 Pyeongchon-dong, Dongan-gu,

Anyang-si, Gyeonggi-do, 431-070,

Korea

Tel.: +82-31-380-3763

Fax: +82-31-386-3761

E-mail: dermakkh@yahoo.co.kr

Melanoma is the second most common tumor in womenof child-bearing age, and it is also one of the most com-mon malignancies diagnosed during pregnancy in Cauca-sians. While the occurrence of malignant tumors inpregnant women is approximately one per 1000 pregnan-cies, malignant melanoma accounts for about 8% of allmalignancies in pregnancy.1 In this case report, we pres-ent a case of malignant melanoma that showed rapid pro-gression during pregnancy.

A 21-year-old woman presented at an estimated21 weeks of pregnancy, complaining of a black nodule onher back. The lesion had first appeared at the age of18 years. However, recently, the lesion had enlarged rap-idly and was accompanied by pruritus. On physical exam-ination, a solitary, asymmetric, well-defined, 1 · 1.5 cmblack nodule was noted on the back (Fig. 1). The histo-logical examination revealed epidermal atrophy and pro-liferation of numerous atypical melanocytes in theepidermis (Fig. 2a). Relatively large and translucent tumorcells were observed in the dermis (Fig. 2b). On immuno-histochemical staining, tumor cells in the dermis werepositive for HMB45 (Fig. 3a), S-100 protein (Fig. 3b),and estrogen receptor (Fig. 3c). On the basis of these fea-tures, we diagnosed the lesion as a nodular malignantmelanoma. After diagnosis, the patient underwent a con-sensual therapeutic abortion. A simultaneously performedplacental biopsy revealed no specific features. Wide

excision and skin transplantation were performed on theback after 10 d. As there were no specific findings fromabdominal ultrasonography or a bone scan, we gradedthe patient with Clark level IV, 2.5 mm in Breslow thick-ness level 3, and stage II (T3N0M0). Subsequently, adju-vant interferon-a immunotherapy was commenced.Twenty-one months after immunotherapy, two 2 · 2 cmnodular lesions were observed on the left axilla. Aspira-tion cytology revealed metastatic melanoma. A bone scanshowed multiple hot uptakes, and metastasis to liver and

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Figure 1 Solitary asymmetric well-defined 1 · 1.5 cm sizedblack nodule on the back

International Journal of Dermatology 2010, 49, 1318–1320 ª 2010 The International Society of Dermatology

lung was observed in abdominal CT. The patient died ofmultiple organ failure during the chemotherapy withtamoxifen, carmustine, dacarbazine, and cisplatin.

Over the past 50 years, case reports and uncontrolledstudies have suggested that nevi are more likely tobecome malignant during pregnancy and that malignantmelanoma diagnosed during pregnancy shows poor prog-nosis.2 The evidence for these suggestions includes areport indicating rapid growth of malignant melanoma inpregnancy,3 the fact that the incidence rate of melanomais higher in women than in men, especially before the ageof 45, the increases in pigmentation that occurs duringthe pregnancy,4 the low incidence of melanoma until afterpuberty, and the increase in growth rate of malignantmelanomas in mice after administration of estrogen.2

However, there are also many indications that pregnancydoes not affect malignant melanoma, including a recentstudy that revealed no significant change in the size ofmelanocytic nevi during pregnancy,5 a cohort study thatshowed melanoma prognosis to be unaffected by preg-nancy,6 and a report that exogenous or endogenousfemale hormones do not contribute significantly toincreased risk of melanoma.7

The hypothesis that the hormonal differences betweenpregnant women and nonpregnant women are related tothe appearance of melanoma has resulted in substantialefforts to find the correlation among women, pregnancy,and pigmentation disorders. However, a clear relationshipbetween hormones and malignant melanoma has not yetbeen established. Recently, estrogen receptor beta wasobserved in melanocytic lesions, especially in dysplasticnevi with severe cytological atypia and lentigo maligna,but further studies on this association are necessary.8

As Asians generally have a lower incidence of malig-nant melanoma, a case such as the study reported here is

(a)

(b)

Figure 2 (a) Epidermal atrophy and the proliferation ofnumerous atypical melanocytes on the dermis (H&E, ·100).(b) Relatively large and translucent tumor cells in the dermis(H&E, ·400)

(a) (c)(b)

Figure 3 Tumor cells in the dermis were positive for HMB45 (a: ·40), S-100 protein (b: ·40) and estrogen receptor (c: ·200)

ª 2010 The International Society of Dermatology International Journal of Dermatology 2010, 49, 1318–1320

Youn et al. Malignant melanoma in pregnancy Case report 1319

relatively rare. Although the skin lesion on this patienthad developed 3 years prior to the first visit, the newsymptoms, such as rapid growth and itching, appearedwith the pregnancy. For this reason, we hypothesize thatthe pregnancy affected the rapid progression and poorprognosis. However, further studies are still required toestablish the relationship between pregnancy, estrogen,and melanoma progression. In addition, while recent clin-ical and laboratory evidence suggests that pregnancy doesnot influence the prognosis of malignant melanoma,deeper infiltration of melanoma has been shown in thethird trimester compared with the first trimester ofpregnancy. Whether this phenomenon was caused by thehormones related to pregnancy or by delayed biopsyduring pregnancy was not established.

In the current case, the patient was diagnosed withClark level IV, which had infiltrated to the reticular der-mis and was 2.5 mm in Breslow thickness by biopsy.Therapeutic abortion and immunotherapy were per-formed immediately after the diagnosis of malignant mel-anoma, upon request by the patient, but she died ofmultiple organ failure. We believe that this was becauseof disease progression, as the detection of the disease hadbeen delayed beyond its early stages.

References1 Vitaliano S, Paola DS, Giustino M, et al. Malignant

melanoma and pregnancy. Melanoma Res 2006; 50:598–603.

2 Driscoll MS, Grant-kels JM. Nevi and melanoma inpregnancy. Dermatol Clin 2006; 24: 199–204.

3 Sato T, Ishiko A, Saito M, et al. Rapid growth ofmalignant melanoma in pregnancy. J Dtsh Dermatol Ges

2008; 6: 126–129.4 Karagas MR, Zens MS, Stukel TA, et al. Pregnancy history

and incidence of melanoma in women: a pooled analysis.Cancer Causes Control 2006; 27: 11–19.

5 Pennoyer JW, Grin CM, Driscoll MS, et al. Changes insize of melanocytic nevi during pregnancy. J Am Acad

Dermatol 1997; 36: 378–382.6 Jasaitiene D, Valiukevieiene S, Makstiene J, Juodzbalient

EB. Metastatic amelanotic nodular melanoma duringpregnancy. Medicina 2008; 44: 467–471.

7 Lens M, Bataille V. Melanoma in relation to reproductiveand hormonal factors in women: current review oncontroversial issues. Cancer Causes Control 2008; 19:437–442.

8 Schmidt A, Nanney LB, Boyd AS, et al. Oestrogen receptorb expression in melanocytic lesions. Exp Dermatol 2006;15: 971–980.

International Journal of Dermatology 2010, 49, 1318–1320 ª 2010 The International Society of Dermatology

Case report Malignant melanoma in pregnancy Youn et al.1320