Small bowel obstruction: a recurrence of melanoma during the second trimester of pregnancy

Proceedings in Obstetrics and Gynecology, Oct 2017

Background: The incidence of melanoma is on the rise in the United States and is particularly prevalent among women of childbearing age. Obtaining a complete history and understanding the unpredictable behavior of melanoma is essential to make the diagnosis of recurrent disease during pregnancy. Case: A 35-year-old G2P1 at 23 weeks and 1 days’ gestation with a remote history of (treated) cutaneous melanoma underwent an exploratory laparotomy for small bowel obstruction. Pathology was consistent with recurrent metastatic melanoma. Conclusion: Metastatic melanoma diagnosed during pregnancy is rare. There are no guidelines on how or when to proceed with treatment of metastatic disease or delivery of the fetus. Immunotherapy is changing the management of melanoma and is extending life expectancy. The significant survival benefits for mother with immunotherapy may outweigh the risks of preterm delivery for the baby.

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Small bowel obstruction: a recurrence of melanoma during the second trimester of pregnancy

Proceedings in Obstetrics and Gynecology Small bowel obstruction: a recurrence of melanoma during the second trimester of pregnancy Lindsay Goad Yousef Zakharia 1 Heather Anaya 0 University of Iowa Hospitals and Clinics, Department of Obstetrics and Gynecology , Iowa City, Iowa , USA 1 University of Iowa Hospitals and Clinics, Department of Internal Medicine , Iowa City, Iowa , USA 2 University of Iowa Carver College of Medicine , Iowa City, Iowa , USA Background: The incidence of melanoma is on the rise in the United States and is particularly prevalent among women of childbearing age. Obtaining a complete history and understanding the unpredictable behavior of melanoma is essential to make the diagnosis of recurrent disease during pregnancy. Case: A 35-year-old G2P1 at 23 weeks and 1 days' gestation with a remote history of (treated) cutaneous melanoma underwent an exploratory laparotomy for small bowel obstruction. Pathology was consistent with recurrent metastatic melanoma. Conclusion: Metastatic melanoma diagnosed during pregnancy is rare. There are no guidelines on how or when to proceed with treatment of metastatic disease or delivery of the fetus. Immunotherapy is changing the management of melanoma and is extending life expectancy. The significant survival benefits for mother with immunotherapy may outweigh the risks of preterm delivery for the baby. Financial Disclosure: The authors report no conflict of interest. Metastatic melanoma; pregnancy; immunotherapy Introduction Melanoma is the most fatal form of skin cancer and is the sixth most common malignancy diagnosed in women.1 The incidence has risen more than any other type of cancer in the last 50 years.2 Melanoma is particularly prevalent among women of childbearing age and is a common malignancy diagnosed in pregnancy, accounting for 8% of all malignancies arising during gestation.3,4 About one third of patients diagnosed with melanoma will have a recurrence later in life.5 Although it is rare, recurrence can present many years later with metastatic disease, with a historical 5-year survival rate of less than 5%.2 There are few cases in the literature in which a patient presents with metastatic melanoma during pregnancy. The majority of cases are diagnosed as a clinically localized skin lesion; few cases present as advanced stage disease, therefore it is unlikely to be included on the list of differential diagnoses. This disease has serious consequences for both mother and fetus. We present a unique case of small bowel obstruction in the second trimester of pregnancy consistent with recurrent metastatic melanoma. Melanoma most commonly metastasizes to the lung, liver, bone and brain and is the most common malignancy to metastasize to the placenta and fetus, although this is exceptionally rare.1,5 It can be diagnosed early in symptomatic presentation with the appropriate imaging, but can be overlooked. It is integral to patient care that a complete history is obtained and that clinicians understand the variable and unpredictable behavior of melanoma as it continues to become more prevalent. Case In January 2016, a 35-year-old woman at 23 weeks and 1-day gestation presented to a local hospital with intractable nausea, vomiting, diffuse abdominal pain and a 10-lb weight loss since her first trimester. She reported having intermittent nausea, vomiting and abdominal cramping for the past two months and was hospitalized overnight early in the course for “gastritis.” Symptoms were thought to be related to pregnancy and were treated accordingly. On presentation, she was afebrile but tachycardic. Her physical exam was significant for an acute abdomen with rebound tenderness and guarding. Abdominal x-ray was concerning for small bowel obstruction. Chest x-ray revealed a left mid lung lesion measuring 4.0 x 3.8 cm. The patient’s past medical history was significant for BRAF negative melanoma diagnosed in 2005 on the right shoulder at an outside hospital. Breslow depth and staging information was not available. She had a wide local excision and negative sentinel node biopsy that required no adjuvant therapy. She had been followed by dermatology biannually with the most recent skin exam in the spring of 2015 at which time she had a premalignant lesion excised from her right ankle. The patient was transferred to a local tertiary care center and underwent an exploratory laparotomy. Intraoperatively, a mass within the small bowel causing an intussusception was excised and the intussusception was reduced. No bowel resection was performed. Multiple liver nodules were seen and a superficial lesion was excised by wedge biopsy and many enlarged lymph nodes were excised from the mesentery. Pathology of the small bowel mass and liver lesion was consistent with BRAF negative metastatic melanoma. Lymph nodes were negative. Following surgery, she presented to our department at 25 weeks and 2 days’ gestation for a treatment plan. The neonatal intensive care u (...truncated)


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Lindsay MD Goad BS, Yousef Zakharia MD, Heather DO Anaya MS. Small bowel obstruction: a recurrence of melanoma during the second trimester of pregnancy, Proceedings in Obstetrics and Gynecology, 2017, Volume 7, Issue 3,