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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)