Malignant melanoma of the vulva. Report of 89 patients

Tumour necrosis is a valuable histopathological prognostic parameter in melanomas of the vulva and vagina

Vulvar and vaginal melanomas (VVMs) are rare and aggressive malignancies with limited prognostic models available and there is no standard reporting protocol. VVMs were selected from six tertiary Canadian hospitals from 2000-2021, resected from patients aged ≥18 years, with 6 months or longer follow-up data, and confirmation of melanocytic differentiation by at least two immunohistochemical markers. Cases were reviewed by pathologists to identify histological biomarkers. Survival outcomes were tested with Kaplan-Meier log-rank, univariate Cox, and multivariate Cox regression. There were 79 VVMs with median follow-up at 26 months. Univariate analysis revealed that tumour necrosis, tumour ulceration, positive lymph nodes, and metastasis at diagnosis were significantly associated with disease-specific mortality, progression, and metastasis. Multivariate analysis identified tumour necrosis as an independent prognostic factor for disease-specific mortality (HR 4.803, 95% CI 1.954-11.803, p<0.001), progression (HR 2.676, 95% CI 1.403-5.102, p=0.003), and time-to-metastasis for non-metastatic patients at diagnosis (HR 3.761, 95%CI 1.678-8.431, p=0.001). Kaplan-Meier survival analyses demonstrated that tumour necrosis was a poor prognostic factor for disease-specific, progression-free, and metastasis-free survival (p<0.001 for all comparisons). Vaginal melanomas displayed decreased survival compared to vulvar or clitoral melanomas. This study identifies tumour necrosis as an independent prognostic factor for VVMs. Vaginal melanomas specifically showed worse survival outcomes compared to vulvar or clitoral melanomas, consistent with previously reported findings in the literature, emphasising the importance of differentiating between these primary tumour epicentres for prognostication and treatment planning in the care of genital melanoma patients.

Melanoma de Mucosa Oral, Genital e Anorretal

Entre 1970 e 1997, 411 pacientes com diagnóstico de melanoma foram atendidos no Hospital São Judas Tadeu de Barretos. Destes, 7 (1,7%) eram de mucosa e os respectivos prontuários foram analisados para este trabalho. Quanto à localização, eram anorretal; 2 eram vulvovaginal, e 1 localizava-se no palato; havia seis pacientes do sexo feminino e um masculino variando as idades de 31 a 81 anos (média = 61 anos). Apenas um paciente apresentou tumor localizado (está com quase 5 anos de sobrevida), 4 tinham doença regional (todos faleceram antes de 3 anos após o diagnóstico) e dois tinham metástases (óbitos ocorridos antes de um ano após diagnóstico). Os tratamentos variaram de conformidade com o estadiamento da doença. Os dados evidenciam o prognóstico ruim da moléstia, que se apresenta, usualmente em estádios avançados e, freqüentemente, com metástases.

A Scoping Review and Population Study Regarding Prevalence and Histopathology of Juvenile Vulvar Melanocytic Lesions. A Recommendation

Cases of vulvar melanocytic lesions in juveniles are rarely reported. We analyze the evidence regarding vulvar melanocytic lesions in juveniles with or without vulvar lichen sclerosus to help decision making by clinicians and pathologists. A scoping review on vulvar melanocytic lesions with or without vulvar lichen sclerosus, including malignant vulvar melanomas, in females up to age 18 years was performed. In addition, the histopathology records of the cohort of all such lesions in The Netherlands from 1991 through 2020 were investigated, and a structured analysis of tissue samples of the subset of cases with lichen sclerosus was performed. The literature study performed confirms that vulvar melanomas in juveniles are extremely rare and that published case reports are often disputed. In The Netherlands, there are no cases of malignant vulvar melanomas up to age 18 years recorded from 1991 through 2020. Atypical histopathological features are often found in biopsies of vulvar nevi in juveniles, especially with concomitant lichen sclerosus, confirming earlier case studies in the literature. We conclude that even with atypical findings, vulvar melanocytic lesions in juveniles have a benign course. To avoid unnecessary and possibly mutilating procedures, we advise referral to an expert center and adaption of existing guidelines for vulvar melanocytic lesions in juveniles.

Vulvar Melanoma: Molecular Characteristics, Diagnosis, Surgical Management, and Medical Treatment

Ten percent of all women have pigmented vulvar lesions. Fortunately, most of these are benign but 1% of all melanomas in women affect the vulva. While the mortality rate of cutaneous melanoma has dropped by 7% annually during the last 5 years, the prognosis of vulvar melanoma remains dismal: the 5-year overall survival rate is 47% compared with 92% for cutaneous melanoma. The current evidence suggests that this likely results from a combination of delayed diagnosis and different tumor biology, treatment strategies, and treatment response. Although many landmark trials on checkpoint inhibitors included mucosal and vulvar melanomas, the results were often not reported separately. Post-hoc analyses indicate overall response rates between 19 and 37% for checkpoint inhibitors. A recently published retrospective study on vulvar melanomas suggests an objective response in 33.3% with a similar safety profile to cutaneous melanoma. Tyrosine kinase inhibitors may be considered in recurrent disease if a c-KIT mutation is present.

Mucosal Melanomas of the Anogenital Tract: Clinical and Pathologic Predictors of Patient Survival

Primary anogenital mucosal melanomas (AGMs) are rare aggressive malignancies that are typically diagnosed at an advanced stage. Ulceration is a common feature in AGMs and may not correlate with outcome. Therefore, staging of AGMs similar to primary cutaneous melanomas, based on tumor thickness and ulceration, may not robustly predict outcome. Derivation of site-specific staging systems is essential for prognostication and optimal management of these patients. To this end, recent retrospective studies have revealed tumor thickness (TT) and mitotic rate (MR) as features of most prognostic significance as follows: in anorectal (TT only) and vulvar (TT and MR) melanomas.

Non-human-papillomavirus-related malignancies of the vulva: A clinicopathological study

BACKGROUND

Malignant tumor of the vulva is the fourth gynecological malignancy in frequency. Close to 70% of all vulvar malignancies are related to high-risk human papillomavirus (HPV) infection.

METHODS

A search for non-HPV-related malignant tumors of the vulva was performed in the last 20 years (2000-2020) in the pathology database of a single tertiary institution. We aim to estimate the prevalence of non-HPV-related malignancies in our population, describe clinicopathological features of these tumors and investigate the expression of some potential therapeutic targets.

RESULTS

A total of 71 patients were recovered; 26 patients (36%) had the diagnosis of extramammary Paget disease, 17 patients (24%) had basal cell carcinomas, 17 patients (24%) had primary melanomas, 10 patients (14%) had metastatic disease to the vulva and one patient (1%) had a primary dermatofibrosarcoma protuberans. Fifty-four percent of patients with extramammary Paget disease had a secondary malignancy and 12.5% had invasive disease. Programmed death-ligand 1 (PDL-1) was positive in seven out of nine primary melanomas and Her2/neu was overexpressed in six out of seven extramammary Paget disease.

CONCLUSION

Non-HPV-related malignancies are important differential diagnoses in patient with vulvar lesions. Additional research is necessary to further understand these complex malignancies and potential new therapeutic targets.

Urethral involvement is associated with higher mortality and local recurrence in vulvar melanoma: a single institutional experience

Vulvar malignant melanoma (VMM), although uncommon, comprises 5-10% of all vulvar malignancies. Local control is notoriously poor in VMM with recurrence rates of 30-50% compared with approximately 3% in cutaneous melanomas. We studied clinicopathologic features of 37 women with VMM, after reviewing three decades of clinical follow-up data in our institutional databases. Most patients were Caucasian (n = 35) with an average age at diagnosis of 60.6 years (range 23-83). The most common subtype was mucosal lentiginous melanoma (n = 25). We compared Kaplan-Meier survival curves of 31 patients defined by clinical and microscopic attributes using exact log-rank tests. Younger patients at diagnosis (23-64 years), those with thin melanomas (≤1 mm), and those with Clark's level II or III tumors had better 5-year survival rates than older patients (65-83 years) and those with thick melanomas (>1 mm) and those with Clark's level IV or V (P ≤ 0.05), respectively, by exact log-rank test. Local recurrence of melanoma occurred in 15 patients. Nine patients (24%) had eventual urethral involvement by malignant melanoma, and this feature was associated with significantly shorter survival (P = 0.036). Patients with urethral involvement had shorter median time to death and worse 5-year survival rates. Given that spread to the urethra is common in VMM and urethral recurrence is also associated with mortality, pathology excision specimens should be carefully reviewed with attention to urethral involvement as a potentially important prognostic factor.

Malignant Melanoma of the Vulva and Vagina: A US Population-Based Study of 1863 Patients

Background

Vulvar melanoma (VuM) and vaginal melanoma (VaM) represent a unique subgroup of malignant melanomas with important differences in biology and treatment.

Objective

The objective of this study was to describe the epidemiology and prognosis of VuM and VaM in a large representative cohort.

Methods

Women with invasive VuM or VaM were identified from the Surveillance, Epidemiology and End Results-18 population representing 27.8% of the US population. Data on age, ethnicity, stage, location, histopathology, primary surgery, and lymphadenectomy were collected. The Kaplan–Meier method was used to analyze disease-specific and overall survival. Univariate and multivariate regression models were used to identify factors with a significant association with disease-specific survival.

Results

A total of 1400 VuM and 463 VaM were included for further analysis; 78.6% and 49.7% of women with VuM and VaM underwent surgery, but only 52.9% of women with non-metastatic VuM and 42.9% of women with non-metastatic VaM undergoing surgery had lymph node assessment; one third of these had positive nodes. Superficial spreading was the most common subtype in VuM, and nodular melanoma in VaM (p < 0.001). The median disease-specific survival was 99 months (95% confidence interval 60–138) and 19 months (95% confidence interval 16–22), respectively. Survival was significantly associated with age at diagnosis, ethnicity, stage, surgery, lymph node metastases, histologic subtype, ulceration, mitotic count, and tumor thickness in VuM, and stage, surgery, and lymph node involvement in VaM. In the Cox model, lymph node status and number of mitoses remained independent predictors of outcome in VuM; in VaM, only lymph node status remained significant.

Conclusions

The overall prognosis of VuM and VaM remains poor. The American Joint Committee on Cancer staging system is applicable and should be used for VuM; however, lymph node status and mitotic rate are the most important predictors of survival. Lymph node status should be assessed and patients with positive nodes may be candidates for adjuvant treatment.

Vulvar malignancies: an interdisciplinary perspective

Vulvar cancer represents the fourth most common gynecologic malignancy and is often encountered by the general Dermatologist or Gynecologist. Dermatooncologists and Gynecologic Oncologists share expertise in this field and the diagnosis and treatment should ideally be interdisciplinary. All subtypes are typically seen in the later decades of life, although all histologic subtypes have been described in women younger than 30 years. The diagnosis is often delayed. Exact mapping of biopsies is of high importance, as the location and distance from the midline guides the surgical approach depending on the underlying histology. Squamous cell carcinoma accounts for more than 76 % of vulvar cancer with vulvar intraepithelial neoplasia being an important precursor. Basal cell carcinoma is the second most common vulvar malignancy. Melanoma accounts for 5.7 % of vulvar cancer and has a worse prognosis compared to cutaneous melanoma. Most of the trials on checkpoint inhibitors and targeted therapy have not excluded patients with vulvar melanoma and the preliminary evidence is reviewed in the manuscript.

Surgery remains the primary treatment modality of locally resectable vulvar cancer. In view of the rarity, the procedure should be performed in dedicated cancer centers to achieve optimal disease control and maintain continence and sexual function whenever possible.

Stage Two Malignant Melanoma of the Clitoris: A Case Report

Mucosal melanomas are rare in comparison to cutaneous melanomas, accounting for approximately 1% of all melanoma cases. Vulvovaginal melanoma is the least common mucosal melanoma subtype. For patients without distant metastases at presentation, regional lymph node involvement is the most important prognostic indicator. Lymphoscintigraphy is a method used to identify the sentinel lymph node (SLN), directing subsequent biopsies to the lymph node at highest risk for cancer spread. We present a 67-year-old Hispanic female with stage II B (T4aN0M0) melanoma of the clitoris. The patient initially sought medical treatment for a pigmented vulvar lesion over her clitoris that occasionally bleeds. She stated that over the past month the lesion began to grow peripherally and then acquired a very dark color. The patient underwent local excision of the mass and subsequent pathology revealed malignant melanoma. The patient underwent lymphoscintigraphy which allowed localization and subsequent biopsy of the left inguinal sentinel node. The left inguinal sentinel node was negative for metastatic melanoma. It was opted to keep her under observation. Compared to cutaneous melanoma, patients with mucosal melanoma usually present with more advanced disease, and thus efficacious imaging practices play a significant role in the management of the disease. Lymphoscintigraphy is a well-tolerated, validated, cost-effective, and reliable method of detecting sentinel nodes with minimal radiation exposure to the patient. In our case, early clinical detection allowed for prompt surgical intervention, pathologic diagnosis, and reliable staging via lymphoscintigraphy of a rare form of malignant melanoma.

Vulvar malignant melanoma: Pathogenesis, clinical behaviour and management: Review of the literature

Vulvar malignant melanoma (VMM) is a rare disease, accounting for 5% of all vulvar malignancies and is characterized by low survival and high recurrence rates. It is considered as a distinct entity of mucosal melanoma. Prognostic factors are higher age, advanced Breslow thickness, and lymph node involvement whilst central localization and ulceration status are still under debate. Surgery is the cornerstone for the treatment of primary VMM, however, it can be mutilating due to the anatomical location of the disease. Elective lymph node dissection is not part of standard care. The value of sentinel lymph node biopsy in VMM is still being studied. Radiation therapy and chemotherapy as adjuvant treatment do not benefit survival. Immunotherapy in cutaneous melanoma has shown promising results but clinical studies in VMM are scarce. In metastatic VMM, checkpoint inhibitors and in case of BRAF or KIT mutated metastatic VMM targeted therapy have shown clinical efficacy. In this review, we present an overview of clinical aspects, clinicopathological characteristics and its prognostic value and the latest view on (adjuvant) therapy and follow-up.

Tumor Thickness and Mitotic Rate Robustly Predict Melanoma-Specific Survival in Patients with Primary Vulvar Melanoma: A Retrospective Review of 100 Cases

Purpose: Primary vulvar melanoma (PVM) is the second most common vulvar malignancy. Despite their distinct anatomic site and unique molecular-genetic alterations, PVMs are staged according to the American Joint Committee on Cancer (AJCC) guidelines for primary cutaneous melanomas (PCM). However, whether parameters derived for PCM also apply to PVM remain a critical yet largely unexplored clinical question. The objective of this study was to determine the parameters predictive of survival in PVM.Experimental Design: We retrospectively reviewed 100 patients with PVM and determined associations between clinical and histopathologic parameters and disease-specific survival (DSS) and overall survival (OS).Results: Univariate Cox regression analysis demonstrated older age (>56 years), greater tumor thickness, higher dermal mitotic rate, ulceration, lymphovascular invasion, perineural invasion, microscopic satellitosis, and absence of precursor nevus associated with decreased OS. Furthermore, age, midline, and/or multifocal involvement, greater tumor thickness, higher dermal mitotic rate, ulceration, lack of regression, lymphovascular invasion, perineural invasion, and microscopic satellitosis associated with decreased DSS. Multivariate analysis demonstrated tumor thickness, dermal mitotic rate, lymphovascular invasion, microscopic satellitosis, and absence of precursor nevus independently predicted shorter OS. Only tumor thickness and increased dermal mitotic rate (≥2/mm²) independently predicted reduced DSS. In comparison with the AJCC T-category, a novel, bivariate T-category based only on tumor thickness and dermal mitotic rate robustly predicted OS and DSS in our patient cohort.Conclusions: In the largest single institutional study of PVM, we demonstrate a combination of tumor thickness and mitotic rate comprise a simple but robust T-category to direct staging and prognosis. Clin Cancer Res; 23(8); 2093-104. ©2016 AACR.

Malignant Melanoma of Vulva and Vagina: A Histomorphological Review and Mutation Analysis--A Single-Center Study

OBJECTIVES

The aim of this work was to determine molecular characteristics and specifically, the frequency of BRAF, C-KIT, and NRAS mutations in vulvar and vaginal melanomas.

METHODS

A retrospective review of all cases of vulvar and vaginal melanoma between 2002 and 2013 was performed. We reviewed the clinical and histological characteristics of all cases and performed genotyping studies on cases that had tissue available for the study, using next-generation sequencing.

RESULTS

We identified 33 vulvar and 11 vaginal melanomas in women with mean ages 58 and 61 years, respectively. Next-generation sequencing analysis on 20 cases (15 vulvar and 5 vaginal) identified a BRAF mutation in 7.6%, C-KIT mutation in 27.6%, NRAS mutation in 27.6%, and TP53 mutation in 7.6% of the vulvar cases. We detected only a single TP53 mutation in the vaginal cases. We did not identify any statistically significant relationship between the mutation status and patients' outcome, depth of invasion, ulceration, stage at presentation, or lymph node metastasis.

CONCLUSIONS

BRAF mutations are infrequent, whereas C-KIT and NRAS mutations are seen with higher frequency in vulvar melanomas than melanomas of other sites. These mutations can be considered as potential therapeutic targets in patients harboring them. Further studies are necessary to increase our understanding of mutational events occurring in melanoma of the lower female genital tract and their relationship with clinical parameters/outcome.

Management of vulvar and vaginal melanomas: current and future strategies

Melanomas arising in the vulva and vagina are rare and therefore there is minimal data specific to these malignancies. Data are often extrapolated from other cutaneous melanomas, which may or may not be appropriate. Surgery remains the primary treatment modality at initial diagnosis and in select recurrent cases. Wide local excision of the primary lesion not requiring an exenteration, along with sentinel lymph node (SLN) mapping, should be routinely considered in vulvar melanomas. Local excision and SLN mapping is difficult and often not considered for vaginal melanomas. Primary exenterative procedures should not be routinely offered. In locally advanced cases potentially requiring an exenterative procedure, radiation therapy with or without concurrent immunotherapy is a consideration. The role of adjuvant therapy remains unclear. Surgery or radiation therapy can be considered in recurrent cases. Systemic chemotherapy agents have a modest response rate with associated poor survival outcomes. Novel immunotherapeutic and targeted agents have been reported to improve survival in melanoma and should be considered in cases of vulvovaginal melanoma. All cases should be tested for at least c-KIT and BRAF V600E mutations. Patients with vulvovaginal melanomas should be strongly encouraged to participate in clinical trials.

Gynecologic Cancer InterGroup (GCIG) consensus review for vulvovaginal melanomas

Vulvovaginal melanomas are rare tumors that account for a small fraction of all vulvovaginal cancers. Biologically, they seem to be similar to mucosal and acral melanomas of other sites. There are limited data specific to vulvovaginal melanomas, especially regarding systemic therapies. Most treatment decisions are based on extrapolation from data regarding cutaneous melanomas of other sites. It is reasonable to follow already established guidelines from other professional groups and societies. Outcomes tend to be worse compared with cutaneous melanomas likely because of the later presentation and physical biological characteristics of these tumors.

Low mutational burden of eight genes involved in the MAPK/ERK, PI3K/AKT, and GNAQ/11 pathways in female genital tract primary melanomas

Mucosal melanomas exhibit discrete genetic features compared to cutaneous melanoma. Limited studies on gynecological melanomas revealed significant heterogeneity and low mutational burden. To gain further insight into their genetics and DNA repair efficiency, we systematically investigated the status of eight genes whose products are critically involved in the MAPK/ERK, PI3K/AKT, and GNAQ/11 pathways, including BRAF, NRAS, HRAS, KRAS, c-KIT, PI3K, GNAQ, and GNA11, in a series of 16 primary gynecological melanomas, covering all anatomical locations, ranging from stages I to III. Analysis either by real-time PCR coupled with fluorescence melting curve analysis or by PCR followed by direct sequencing, along with studies for DNA mismatch repair status using immunohistochemistry, disclosed that 15 out of the 16 cases displayed wild-type genotypes, with a single case of vulvar primary melanoma, harboring the activating mutation BRAF(V600E). Investigations on whether this could reflect partly an efficient mismatch repair (MMR) mechanism were confirmed by normal expression of hMLH1 and hMSH2, suggesting that the lack of mutations could be explained by the operation of alternative pathogenetic mechanisms modulating downstream effectors of the signaling pathways. Our data suggest the presence of additional genetic components and provide the impetus for systematic approaches to reveal these yet unidentified genetic parameters.

A clinicopathological review of 33 patients with vulvar melanoma identifies c-KIT as a prognostic marker

Vulvar melanoma is the second most common vulvar cancer. Patients with vulvar melanoma usually present with the disease at a late stage and have a poor prognosis. The prognostic predictors reported in the literature are not unequivocal and the role of lichen sclerosus and c-KIT mutations in the aetiology of vulvar melanoma is unclear. Breslow staging currently seems to be the most adequate predictor of prognosis. We thus performed a clinicopathological and literature review to identify suitable predictors of prognosis and survival and investigated the expression of c-KIT (by immunohistochemistry) in patients with vulvar melanoma (n=33) from the Gynaecological Cancer Centres of the Royal Hospital for Women (Sydney, Australia) and John Hunter Hospital (Newcastle, Australia). Our series of 33 patients fitted the expected clinical profile of older women: delayed presentation, high stage, limited response to treatment and poor prognosis. We identified 3 patients (9.1%) with lichen sclerosus associated with melanoma in situ, although no lichen sclerosus was found in the areas of invasive melanoma. No patient had vulvar nevi. We identified a) Breslow's depth, b) an absence of any of the pathological risk factors, such as satellitosis, in-transit metastasis, lymphovascular space invasion (LVSI) and dermal mitosis, c) removal of inguino-femoral lymph nodes, d) lateral margin of >1 cm, and e) c-KIT expression as valuable prognostic predictors for disease-free survival. We conclude that c-KIT expression is, apart from Breslow's depth, another valuable predictor of prognosis and survival. Lichen sclerosus may be associated with vulvar melanoma.

Features of pigmented vulval lesions on dermoscopy

BACKGROUND

The dermoscopic criteria for benign and malignant lesions on the vulva are not well established due to the lack of large series of such lesions. Melanoma should always be included in the differential diagnosis of pigmented lesions on the vulva especially when they are wide, or of recent onset. Elsewhere on the skin dermoscopy plays an important role in the selection of suspicious pigmented lesions, as well as in the selection of the best site to perform the biopsy.

OBJECTIVES

To analyse the dermoscopic patterns observed in pigmented lesions of the vulva.

METHODS

We analysed a nonselected consecutive series of 68 histopathologically proven cases comprising five melanomas, 16 naevi, 20 lentigos, 12 benign vulval melanoses, 11 cases of postinflammatory pigmentation, three pigmented cases of usual vulval intraepithelial neoplasia (VIN) and one seborrhoeic keratosis seen at our institution. The dermoscope was covered by translucent disposable food wrap and/or antibacterial gel to prevent possible transmission of infections. Descriptive statistics were performed using multiple correspondence analysis.

RESULTS

The parallel (37%), ring-like (9%), homogeneous (22%), globular-like (13%) and reticular-like (6%) patterns were observed on benign lesions (naevi, lentigo, vulval melanosis and postinflammatory pigmentation). The cerebriform pattern (6%) was observed only on VIN and seborrhoeic keratosis. The multicomponent pattern (6%) was associated with melanoma (60%). In cases of melanoma we also occasionally observed an irregular pattern, a whitish or blue-whitish veil, irregularly distributed dots and globules and atypical vascular pattern. Using multiple correspondence analysis, we designed a new algorithm for the early detection of vulval melanomas.

CONCLUSIONS

Dermoscopy can play a role in the noninvasive classification of vulval melanosis. However, further studies of larger collaborative series are needed to validate our vulval melanoma diagnostic algorithm. VIN and seborrhoeic keratosis share the same dermoscopic features and biopsy should be considered for seborrhoeic-like keratosis. In case of doubt pathological examination of a biopsy remains mandatory.

Vulvar melanoma: report on eleven cases and review of the literature

CONTEXT AND OBJECTIVE

Vulvar melanoma is a rare disease. We describe the experience of a single institution and review the literature.

DESIGN AND SETTING

Retrospective study at the Department of Gynecology, Hospital do Cancer A. C. Camargo.

METHODS

Eleven patients with vulvar melanoma attended between January 1987 and December 2006 were reviewed regarding clinicopathological characteristics, surgical therapy and follow-up.

RESULTS

The initial symptoms were vulvar lesions, pruritus, pain and bleeding. The median age was 64.8 years. The median depth of invasion was 3.08 mm. The staging ranged from IB to IIIC (American Joint Committee on Cancer, 2002). All the patients underwent vulvectomy. Two patients did not undergo primary elective lymphadenectomy. Bilateral inguinal lymphadenectomy was performed on five patients, and one had unilateral inguinal lymphadenectomy. Sentinel lymph node investigation was performed on three patients. Five patients had locoregional recurrence. Prolonged survival was only achieved in the absence of lymph node involvement. The median follow-up was 56 months. The median disease-free survival was 15 months and the median overall survival was 29 months.

CONCLUSIONS

The prognosis for patients with vulvar melanoma is generally poor, with a high tendency towards regional and distant recurrence. Depth of invasion and lymph node involvement are the most important prognostic factors. In most cases, resection of the lesion with adequate margins may replace vulvectomy. Elective inguinal femoral lymphadenectomy remains the standard lymph node staging procedure. Sentinel lymph node investigation is feasible and should be performed by a multidisciplinary team with experience of this method.

Vulvar Melanoma

OBJECTIVES

To determine the prognostic factors associated with the survival of vulvar melanoma patients.

METHODS

Data were obtained from the Surveillance Epidemiology and End Results database from 1973 to 2003. Kaplan-Meier survival curves and Cox regression models were used for analysis.

RESULTS

Of the 644 vulvar melanoma patients, the median age was 68 years. Of these 572 women were white, 28 were Hispanic, 18 were African-American, and 14 were Asian. A total of 302 had localized disease, 168 had regional disease, and 28 had distant disease. Of the participants who underwent surgical resection, 171 (26.6%) had conservative surgery, 164 (25.5%) had radical excision, and 241 (37.5%) had unspecified surgical resections. One hundred seventy-nine (27.8%) had lymph node resections, and 33 patients had concurrent radiation therapy. Nodal metastases were identified in 58 (9%) of the participants. The 5-year disease-specific survival rates for those with localized, regional, and distant disease were 75.5%, 38.7%, and 22.1%, respectively (P<.001). Women aged 68 years or younger had a better survival rate than older patients (72.0% compared with 47.7%; P<.001). Those with 0, 1, and 2 or more positive lymph nodes had survival rates of 68.3%, 29%, and 19.5%, respectively (P<.001). In a multivariable analysis, younger age, localized disease, and negative lymph nodes were independent prognostic factors for improved survival.

CONCLUSION

Age, stage, and lymph node involvement were significant factors for survival in vulvar melanoma.

LEVEL OF EVIDENCE

III.

Biochemotherapy in patients with advanced vulvovaginal mucosal melanoma

Patients with advanced vulvovaginal mucosal melanoma generally have a dismal prognosis, and no effective systemic therapy for the disease has been reported. The objective of this retrospective clinical study was to assess the clinical benefit of biochemotherapy in this patient population. We evaluated the medical records of all patients with advanced vulvovaginal mucosal melanoma treated with biochemotherapy at our institution. Our search yielded 11 patients with adequate documentation for study inclusion: eight patients had undergone treatment with cisplatin (CDDP), vinblastine (VB), dacarbazine (DTIC), interferon-alpha (IFN) and interleukin-2 (IL-2), one with CDDP, VB, DTIC and IFN, one with CDDP, temozolomide and IFN, and one with CDDP, VB, DTIC, tamoxifen, IFN and IL-2. All IL-2 treatments were administered intravenously. The median follow-up duration was 10 months (range, 2-44 months). Four patients (36%) showed partial responses, but none showed a complete response. Two patients did not return for follow-up evaluation after the completion of treatment. The median time to disease progression in all 11 patients was 3 months; however, the median time to disease progression in those with a partial response or stable disease was 6 months. One patient was alive at the last documented follow-up visit (51 months). The median overall survival duration from the start of biochemotherapy was 10 months. Biochemotherapy appears to have significant activity against advanced vulvovaginal melanoma, and should be considered as a systemic treatment option for advanced, metastatic, vulvovaginal melanoma.

Recurrent primary vulvovaginal malignant melanoma arising in melanoma in situ--the natural history of lesions followed for 23 years

Multifocal melanoma and melanoma in situ of the vulva and vagina are uncommon lesions, and our understanding of their natural history is limited. Vulvovaginal melanoma appears to be biologically different from cutaneous melanoma and has more in common with mucosal melanoma. A 60-year-old woman presented in 1977 with a pigmented vulvar lesion. Histologic examination revealed melanoma in situ associated with focal invasive melanoma. She re-presented with recurrent primary melanomas arising in melanoma in situ in 1990 and 1998 and died of widespread metastatic melanoma in 2000. Melanoma in situ of the vulva and vagina is rare and appears to have a relatively slow but definite progression to invasive melanoma. All suspicious pigmented lesions in this region should be biopsied, and if multifocal in situ melanoma is identified, vulvo(vagin)ectomy should be considered.

Primary vulvar melanoma with satellite metastasis: dermoscopic findings

A 79-year-old woman presented with a 1-year history of a pigmented nodular lesion on the left labium minor. Histopathology of the nodule led to a diagnosis of metastatic melanoma. A pigmented flat lesion on the inner side of the left labium major was also biopsied and was found to be a superficial spreading melanoma. The dermoscopic findings of primary and metastatic vulvar melanoma which simultaneously occurred in the same patient are described. Dermoscopy revealed a homogeneous pattern associated with linear irregular vessels in the metastatic nodule, while irregular globules and streaks were seen in the primary melanoma.

Modern management of vulvar cancer

PURPOSE OF REVIEW

The radical surgical approach in the treatment of vulvar cancer patients has led to a favourable prognosis for the majority of patients with early stage vulvar cancer. However, morbidity is impressive, leading to more individualized treatment. The authors have reviewed the most recent literature on the pros and cons of the modifications in treatment, including surgery and primary radiotherapy, for primary squamous cell carcinoma of the vulva and vulvar melanoma.

RECENT FINDINGS

The sentinel lymph node procedure is a promising method of staging in patients with early stage squamous cell carcinoma of the vulva and possibly for patients with vulvar melanoma, but its safety still has to be proved. Less radical surgery has led to a higher local and regional recurrence rate. There may be a role for primary radiotherapy of the groin in a selected group of patients.

SUMMARY

The authors have concluded that the individualization of treatment for vulvar cancer patients has led to a decrease in morbidity but an increase in recurrences. The increase in recurrences does not appear to compromise prognosis, probably because of the lack of power, based on the low incidence of vulvar cancer. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce the morbidity of treatment but their safety needs to be studied in randomized trials.

Groin surgery and the sentinel lymph node

Vulvar cancer is a rare disease. Squamous-cell carcinomas account for 90% of vulvar cancers. The main mode of spread is lymphogenic to the inguinofemoral lymph nodes. Therefore, elective uni- or bilateral inguinofemoral lymphadenectomy is part of the standard treatment in combination with radical (wide) local excision of the vulvar tumour. Lymph drainage studies in relation to the biological behaviour of vulvar cancer are presented, as well as the anatomy and surgery of the groin. The sentinel lymph node procedure is a relatively new method of staging in vulvar cancer which may lead to the omission of inguinofemoral lymphadenectomy in those patients identified as not having inguinofemoral lymph node metastases. The accuracy of this technique appears to be high, but its safety still has to be proven. Moreover, the role of additional histopathological techniques for the examination of the sentinel lymph nodes needs to be established.

Bartholin's gland carcinoma, malignant melanoma and other rare tumours of the vulva

Non-squamous cancers of the vulva encompass an exciting and broad group of tumours, including Bartholin's gland carcinoma, malignant melanoma, Paget's disease, sarcomas and lymphoma. These tumours range from innocuous lesions treatable with simple local excision, such as basal-cell carcinoma, to cancers with very poor prognosis, such as Merkel-cell tumours. All of these tumours are thoroughly reviewed, with emphasis on presenting symptoms, pathological diagnosis and optimal management approaches. The literature supporting these recommendations is reviewed. Of the utmost importance in the management of these tumours is a thorough review of the pathological diagnosis by a specialist pathologist and a gynaecological oncologist. Establishing the correct diagnosis is essential to reaching appropriate treatment decisions. Frequently this will necessitate a second opinion by a referral centre.

Changes in the management of vulval cancer

Vulval carcinoma is relatively rare. The disease spreads from the vulva through embolization to the locoregional lymphatic station, the inguinofemoral nodes. Prior to this event cure can be achieved, but rarely predicted with certainty. This chapter reviews current therapeutic knowledge and recognizes the increasing importance of individualization of a treatment plan. The adoption of these principles will hopefully evolve a pattern of care that leads to a decrease in morbidity for those women with early tumours and less morbid but more effective strategies for those with advanced disease.

Mucosal melanoma of the female genital tract is a multifocal disorder

OBJECTIVE

This is a retrospective analysis of malignant melanoma of the female genital tract, focusing on the high local recurrence rate of this tumor.

METHODS

All women treated for malignant melanoma of the genital tract were identified through the archives of the Hadassah University Hospital. The medical records and the pathological specimens were reviewed and reevaluated.

RESULTS

From 1986 to 2002, nine cases were diagnosed and treated at Hadassah. Seven had vulvar melanoma and two had vaginal melanoma. Sixty-six percent (6/9) of the patients had more than one focus of melanoma, either apparent at their initial diagnosis (3/9) or developed during follow up (3/9). Most of the recurring lesions were melanoma in situ. In one patient multiple nodular melanomas were detected. Atypical melanocytic hyperplasia was found in an otherwise normal mucosa in four patients. Three had experienced multiple recurrences. All patients were treated by radical local excisions with (3/9) or without (6/9) elective groin lymph node dissection. Three patients with locally recurring melanoma within the genital tract required two to five sessions of repeated surgical excisions.

CONCLUSION

It is suggested that melanoma of the genital tract is the result of a multifocal disorder of the melanocytes within the mucosa. The increased local recurrence rate reflects an inherent abnormality of melanocytes. It is not attributed to surgical failure in controlling the disease. Insistent and even radical surgical excision is recommended, especially for patients whose prospects for prolonged survival are improved.

Vulvar malignant melanoma associated with human papillomavirus DNA: report of two cases and review of literature

Oncogenic human papillomavirus (HPV) types such as HPV 16 are known to play a crucial role in the development of anogenital carcinomas. The etiology of anogenital malignant melanoma is unknown. We report two case of vulvar malignant melanoma in which multiple HPV types including HPV 16 and putative novel HPV types (alb-1, alb-2, alb-7, and alb-10) were identified by degenerated nested polymerase chain techniques (polymerase chain reaction) in both the malignant melanoma and surrounding skin. One melanoma was associated with lichen sclerosus, and the other, with melanoma in situ and pigmented vulvar squamous papillomatosis. These melanomas harbored HPV types alb-7, and HPV 16 as well as alb-1, respectively. HPV types 16, 20, 21, 36, alb-2, and AJ001060 were detected in vulvar skin affected by lichen sclerosus. Vulvar squamous papillomatosis harbored HPV types 28 and alb-10. HPV 16 was physically integrated into the host genome in lichen sclerosus skin and possibly in the melanoma associated with pigmented vulvar squamous papillomatosis. Twenty-two percent (4 of 18) of normal control specimens from skin tumor excisions were found to harbor HPV DNA (HPV types 3, 54, and alb-7); none of these control samples harbored multiple HPV DNA. These findings of multiple HPV DNA and integrated HPV 16 in skin associated with vulvar malignant melanoma indicate that HPV may play a role in the development of vulvar malignant melanoma. The role of HPV could be either direct through infection of melanocytes or indirect as a cofactor with free radicals in chronic fibroinflammatory vulvar disorders such as lichen sclerosus.

Vulvar melanoma: is there a role for sentinel lymph node biopsy?

BACKGROUND

The objective of this study was to evaluate the author's recent, preliminary experience with the sentinel lymph node procedure in patients with vulvar melanoma and to compare this experience with treatment and follow-up of patients with vulvar melanomas who were treated previously at their institution.

METHODS

From 1997, sentinel lymph node procedure with the combined technique (99mTechnetium-labeled nanocolloid and Patente Blue-V) was performed as a standard staging procedure for patients with vulvar melanoma with a thickness > 1 mm and no clinically suspicious inguinofemoral lymph nodes. For the current study, clinicopathologic data from all 33 patients with vulvar melanoma who were treated between 1978 and 2000 at the University Hospital Groningen were reviewed and analyzed.

RESULTS

From January 1997 until December 2000, identification of sentinel lymph nodes was successful in all nine patients who were referred for treatment of vulvar melanoma. Three patients underwent subsequent complete inguinofemoral lymphadenectomy because of metastatic sentinel lymph nodes. In follow-up, groin recurrences (in-transit metastases) occurred in two of nine patients, both 12 months after primary treatment. Both patients had melanomas with a thickness > 4 mm and previously had negative sentinel lymph nodes. There was a trend toward more frequent groin recurrences in patients after undergoing the sentinel lymph node procedure (2 of 9 patients) compared with 24 historic control patients (0 of 24 patients; P = 0.06). Five of 33 patients developed local recurrences: Two patients had groin recurrences, and 11 patients developed distant metastases. Twelve patients died of vulvar melanoma. Seventeen patients with a median follow-up of 66 months (range, 9-123 months) are currently alive (overall survival rate, 52%).

CONCLUSIONS

Although the numbers were small, this study showed that the sentinel lymph node procedure is capable of identifying patients who have occult lymph node metastases and who may benefit from lymphadenectomy for locoregional control and prevention of distant metastases. However, the data also suggest that the sentinel lymph node procedure may increase the risk of locoregional recurrences (in-transit metastases), especially in patients with thick melanomas. The potential role of the sentinel lymph node procedure as an alternative method of lymph node staging in patients with vulvar melanoma needs further investigation only within the protection of clinical trials and probably should be restricted to patients with melanomas with intermediate thickness (1-4 mm).

Vulvar melanoma at the M. D. Anderson Cancer Center: 25 years later

The purpose of this study was to review the clinical course of patients diagnosed with vulvar melanoma. Charts of patients diagnosed between 1970 and 1997 were reviewed for demographics, lesion characteristics, disease duration and extent, and treatments. Actuarial survival curves were computed by the Kaplan Meier method and compared by Cox proportional hazards regressions. Fifty-one patients (median age 54) with vulvar melanoma presented with a vulvar mass (39%), pain (30%), bleeding (24%), and itching (20%). Anatomical distribution was mucosa of the vulva (65%), vulvar epidermal site (21%), or unspecified vulva (14%), with 20% having multifocal disease at diagnosis. Histologic types were superficial spreading or nodular (50% each). Median lesion characteristics were diameter 2 cm, Breslow index 4.4 mm, and Clark level IV. Distribution of patients per American Joint Committee on Cancer (AJCC) stage was 29%, 50%, 16%, and 7% for stages I, II, III and IV, respectively. Inguinal node metastases were unilateral in 16% and bilateral in 7%. Despite complete surgical resection, 32 patients (63%) recurred. Median survival for all patients was 41 months (range, 5-324), with 91% 5-year survival for patients with stage I and 31% for stage >or= IIA (P = 0.0002). As with cutaneous melanoma, the AJCC classification, Breslow's thickness, and Clark's levels are the major predictors of overall survival (P = 0.0001 each) and disease-free survival (P <or= 0.0001, 0.0004, and 0.0002, respectively). Surgical techniques do not seem to alter the prognosis. Because vulvar melanoma carries a poor prognosis at early stages, the use of adjuvant therapies needs to be studied prospectively in women affected with this disease.

The value of tan lines: vulvar melanoma and ultraviolet rays

Recreational sun exposure of the general population has increased. There is less clothing on the beaches, increased accessibility to tropical beaches, and increased use of artificial suntanning equipment. The vulva, traditionally, has been protected from sun exposure. In this age of nude sunbathing, particularly within the confines of a tanning bed, it is interesting to ponder whether such exposure would affect the incidence of melanoma of the vulva.

Recent developments in the pathology of melanocytic neoplasia

This article selectively discusses clinically relevant aspects of the pathology of cutaneous melanocytic neoplasms, from the literature of the past recent years. Topics include the changing role of immunohistochemistry in diagnosis, the controversies over dysplastic nevi, description of other specialized variants of melanocytic nevi, diagnosis of melanocytic neoplasms of acral skin, and melanoma occurring in childhood. Several variants of melanoma including desmoplastic and spindle-cell types, verrucous melanoma, epidermotropic melanoma, and melanoma of the female genitalia are reviewed. The issue of appropriate margins of resection for melanoma and the use of Mohs Micrographic surgery for this tumor are considered. Finally, a review of the sentinel node biopsy technique and of nodal nevi is presented.

A survey of hospital management practices for vulvar melanoma

BACKGROUND

Vulvar melanoma is a very rare form of cancer. The purpose of this study was to describe practice patterns for the management of vulvar melanoma.

STUDY DESIGN

The National Cancer Data Base was reviewed from 1985 through 1994 for patient reports submitted with a diagnosis of vulvar melanoma.

RESULTS

Five hundred sixty-nine patients with vulvar melanoma were identified. A substantial number of patients were older; during the latter period of this study (1990 to 1994), 50% were 70 years old or older. Surgery was used in more than 90% of patients with stages 0 to III. Local excision was used mainly in early-stage (0 and I) disease. Adjuvant therapy was used infrequently. Lymph node evaluation was performed in more than half of the patients, with greater frequency for patients who had advanced disease. The overall 5-year relative survival rate was 62%. If the lymph nodes contained metastases, survival was poor. Patients with recurrent disease also had poor survival.

CONCLUSIONS

Surgery remains the mainstay of therapy for vulvar melanoma. The use of excision and radical operations remained constant during the 10 years of the study.

Primary mucosal and glans penis melanomas: the Sydney Melanoma Unit experience

BACKGROUND

Melanomas that arise on mucosal surfaces and the glans penis are rare.

METHODS

A retrospective study of the Sydney Melanoma Unit experience with 69 patients treated since 1956 for these types of melanomas was undertaken to determine primary lesion site, sex, age at diagnosis, symptoms, clinical stage at first presentation. histopathology, treatment and outcome.

RESULTS

Primary lesion sites were: nasal cavity (n = 9), oral cavity (n = 16), vulva/vagina (n = 25), anus/rectum (n = 13) and glans penis (n = 6). At diagnosis, 55 patients had local disease only, eight had regional lymph node metastases and six had widespread disease. Local recurrence as the first sign of relapse developed in 15 of the 55 stage I patients (three-stage system). Prognosis for the entire group was poor, only 10% being disease free 3 years after diagnosis and overall 3- and 5-year actuarial survival being 40% and 23%. respectively. The only statistically significant factor influencing survival was stage of disease at diagnosis (P = 0.002).

CONCLUSIONS

Possible reasons for poor survival include: (i) non-specific symptoms resulting in late presentation; (ii) locally advanced disease not being recognized by a clinician as a rare form of melanoma, resulting in a delay in treatment; (iii) anatomical constraints precluding surgery with generous margins and consequently resulting in a high incidence of local recurrence. Also, rich vascularity and multiple lymphatic drainage pathways may mean a predisposition to early dissemination. Prompt diagnosis and referral to a specialist unit for treatment and follow up are essential. Adequate surgery remains the cornerstone of treatment for these types of melanoma until more effective systemic therapies become available.

[Managing cutaneous melanoma]

Cutaneous melanoma represents the main cause of death among skin cancers. Early diagnosis gives, for the time being, the only possibility for high rate of curative treatment. Diagnosis is based on pathological findings, and at primary tumor stage. Breslow thickness of the lesion is the best prognostic index. At local stage of the disease, treatment is precisely codified by international recommendations and consensus conferences. Follow-up after surgical treatment is also well codified. Treatment of lymph node invasion or metastatic disease is, on the other hand, less codified. Despite recent advances, especially in immunotherapy, treatment of advanced stages of melanoma remains difficult.

Malignant melanoma of the mucous membranes: a review of 119 cases

BACKGROUND

Melanomas arising from the mucous membranes lining the respiratory, digestive, and genitourinary tracts are rare. Women are more commonly affected than are men, mainly because there is no male counterpart for vulvovaginal lesions. The mainstay of therapy is surgery, with little current use of adjuvant modalities in primary therapy. These lesions usually are advanced at initial presentation; consequently, the prognosis is poor, with 5-year survivals well below 50% in most series.

METHODS

One hundred and nineteen patients with primary mucosal melanoma were reviewed. They represented 1.1% of the 10,393 melanoma patients seen at Duke University between 1970 and 1995. All data were obtained from the patients' clinic charts and computerized databases.

RESULTS

There were 43 tumors arising from the head and neck region, 46 from the urogenital tract, and 30 from the anorectum. A female predominance was observed, with a female-to-male ratio of 2.7:1. All but five of the patients underwent resection with curative intent. Regional or distant metastases, or both, were encountered in 36 patients at the time of presentation. In patients with head and neck and urogenital tumors, local recurrences accounted for most of the treatment failures, whereas systemic recurrences were more common with tumors arising in the anorectum. The age and gender of the patient, anatomic site of origin of the tumor, clinical stage at initial presentation, and ulceration of the primary all clearly affected prognosis. Overall, the probabilities of being alive 1, 5, and 10 years after diagnosis were 80%, 29%, and 15%, respectively.

CONCLUSIONS

Widely accepted classification systems are needed so that results from separate institutions can be compared adequately. Multi-institutional trials could help in delineating standardized therapeutic protocols and in establishing the potential roles of emerging modalities in the treatment of this subtype of melanoma.

Long-term disease-free survival following surgery and active specific immunotherapy with allogeneic vaccine in a patient with high-risk malignant melanoma of the vulva

Vulvar malignant melanoma with deep vertical penetration of the tumor and involvement of regional lymph nodes carries a very poor prognosis. The case of a 25-year-old woman with a history of a Breslow depth 6.0 mm and Clark Level IV primary vulvar malignant melanoma, involving the anterior part of the left labium major, 1 cm from the clitoris, is reported. The patient had undergone a left radical hemivulvectomy and bilateral groin dissection. There were two of thirteen superficial left groin nodes containing metastatic melanoma. The patient had been treated postoperatively with an allogeneic specific anti-melanoma vaccine in combination with high-dose cimetidine and has survived without disease for more than five years. To the best of our knowledge this is the first case report in the literature of active specific immunotherapy with allogeneic vaccine in vulvar malignant melanoma. This case illustrates that the behavior of malignant melanoma, including vulvar malignant melanoma, is unpredictable and active specific immunotherapy with allogeneic vaccine may have a role in the postoperative treatment of high risk vulvar malignant melanoma.