Complete Response After Stereotactic Body Radiation Therapy With Concurrent Immunotherapy for Vaginal Melanoma

Usage of nivolumab and ipilimumab for recurrent or advanced malignant vaginal melanoma: a two-case series

Immune checkpoint inhibitors help treat malignant melanoma, but show limited use in treating malignant vaginal melanoma, an aggressive, rare gynecological malignancy. We identified two patients treated with ipilimumab and nivolumab for vaginal melanoma; both were immunonegative for programmed cell death-ligand 1 and wild-type BRAF. Case 1, a 56-year-old female who underwent radical surgery for stage 1 malignant vaginal melanoma, experienced recurrence 15 months postoperatively. She briefly responded to ipilimumab and nivolumab combination therapy before showing disease progression. Tumor shrinkage occurred with nivolumab and local radiotherapy and, 45 months postoperatively, she survives with the melanoma. Case 2, a 50-year-old female, presented with a 4-cm blackish polypoid vaginal tumor with metastatic pelvic lymph nodes. She received ipilimumab and nivolumab combination therapy for stage III unresectable malignant vaginal melanoma. The vaginal tumor shrank after the third course of treatment, and the lymphadenopathy disappeared. The patient underwent radical surgery and is currently disease-free, using nivolumab for maintenance therapy. Both patients had immune-related adverse events coinciding with periods of high therapeutic efficacy of immune checkpoint inhibitors. Neoadjuvant therapy with immune checkpoint inhibitors and radiotherapy for immune checkpoint inhibitor resensitization may effectively treat advanced or recurrent vaginal melanoma.

The Role of Radiotherapy in the Management of Vaginal Melanoma: A Literature Review with a Focus on the Potential Synergistic Role of Immunotherapy

Among the mucosal melanomas, vaginal melanomas are very rare tumors, accounting for less than 20% of melanomas arising from the female genital tract. They occur most frequently in women in post-menopausal age, but younger patients may also experience this neoplasm, mainly located in the lower third of the vagina or the anterior wall. The optimal management of this tumor remains controversial, with surgery reported as the most frequently adopted approach. However, a clear benefit of surgical treatment in terms of survival has not yet been demonstrated. Conversely, radiotherapy may represent an attractive non-invasive alternative, and there are several favorable reports of the role of radiation therapy, either delivered with photons, brachytherapy, or hadrontherapy. A wide range of techniques and fractionation regimens are reported with substantially good tolerance to the treatment, and acute G3 or higher toxicities are reported only in the case of concurrent immunotherapy. Of note, due to the rarity of the disease, there is a lack of high-level evidence for the optimal therapeutic option. In this scenario, recent studies theorize the possibility of developing combinatorial approaches of radiotherapy with immunotherapy based on cutaneous melanomas reports. In this review, we aim to summarize the evidence available in the literature supporting the role of definitive radiotherapy for vaginal melanomas, with a focus on the combination of RT with immunotherapy, in terms of optimal timing and biological rationale.

Near complete remission of a locally advanced giant melanoma of the vulva following hypo-fractionated radiotherapy and immune checkpoint inhibitors: A case report

Melanoma is known to be insensitive to radiotherapy; however, the present study reports the case of a patient with vulvar malignant melanoma in which near complete remission of the target area was observed after implementing immune checkpoint inhibitors (ICIs) and hypo-fractionated radiotherapy (HFRT). The patient was treated with an intensity-modulated radiation therapy technique that delivered a hypo-fractionated dose of 3,000 cGy in six fractions. After 3 days, the patient underwent immunotherapy with two cycles of 240 mg triprizumab every 2 weeks. Tumors that underwent radiotherapy had markedly decreased in size and a near complete remission of the melanoma was observed 4 months after radiotherapy. However, the metastases in the liver and lungs continued to grow, new metastases appeared in the abdominal subcutaneous tissue and enlarged lymph nodes were observed in the pelvic area. The results of the present study indicated that ICIs and HFRT exert a marked local effect, but no abscopal effect.