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

Primary vulval melanoma and genital lichen sclerosus

Background

Lichen sclerosus (LS) is a chronic, inflammatory skin disease with a predilection for the genitalia. Although, the association between squamous cell cancer and genital LS is well established, a link with genital melanoma has not been thoroughly explored. However, we have recently published a case series of penile melanoma where 9/11 (82%) of patients seen over a 10 year period with penile melanoma were retrospectively found to have histological and/or clinical evidence of genital LS on review.

Objectives

The aim of this study was to illuminate further the relationship between vulval melanoma and genital LS by reviewing all the cases managed by our hospital and undertaking a literature review.

Methods

We identified all the cases with a diagnosis of vulval melanoma over a 16-year period (2006-2022) where histology was available. The clinical notes were retrospectively reviewed, and the histological features of all cases were reassessed by two independent mutually 'blinded' histopathologists. We also performed a literature review of genital LS in patients with vulval melanoma.

Results

A total of 11 patients with vulval melanoma were identified for the review. Histopathological review found evidence of genital LS in seven of them (64%). Genital LS was not documented in any of the original histology reports. Clinical notes and letters were available in nine cases. The literature review identified 12 relevant studies with a total of 18 patients. Twelve cases concerned adult women, and six concerned female children.

Conclusion

The presence of genital LS in as high as 64% of our vulval melanoma cases might indicate a causative relationship between genital LS and vulval melanoma. The pathogenesis of vulval melanoma remains largely unknown. Although ultraviolet radiation is an important pathogenic factor for cutaneous melanoma, it cannot be a factor in vulval melanoma. While possible mechanisms behind this association remain unclear, it is possible that chronic inflammation from genital LS leads to melanocytic distress and increased mutagenesis.

Retrospective Analyses of PD-L1, LAG-3, TIM-3, OX40L Expressions and MSI Status in Gastroenteropancreatic Neuroendocrine Neoplasms

We investigated expressions of PD-L1, LAG-3, TIM-3, and OX40L as immune checkpoint proteins, and MSI (repetitive short-DNA-sequences due to defective DNA-repair system) status were analyzed with immunohistochemistry from tissue blocks. Of 83 patients, PD-L1 expression was observed in 18.1% (n = 15) of the patients. None of the patients exhibited LAG-3 expression. TIM-3 expression was 4.9% (n = 4), OX40L was 22.9% (n = 19), and 8.4% (n = 7) of the patients had MSI tumor. A low-to-intermediate positive correlation was observed between PD-L1 and TIM-3 expressions (rho: 0.333, p < 0.01). Although PD-L1 expression was higher in grade 3 NET/NEC, MSI status was prominent in grade 1/2 NET.

Epidemiologic characteristics and a prognostic nomogram for patients with vulvar cancer: results from the Surveillance, Epidemiology, and End Results (SEER) program in the United States, 1975 to 2016

OBJECTIVE

To elucidate clinical characteristics and build a prognostic nomogram for patients with vulvar cancer.

METHODS

The study population was drawn from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly assigned to training and validation sets. Cox proportional hazards model and competing risk model were used to identify the prognostic parameters of overall survival (OS) and cancer-specific survival (CSS) to construct a nomogram. The nomogram was assessed by concordance index (C-index), area under the curve (AUC), calibration plot, and decision curve analysis (DCA).

RESULTS

A total of 20,716 patients were included in epidemiological analysis, of whom 7,025 patients were selected in survival analysis, including 4,215 and 2,810 in training and validation sets, respectively. The multivariate Cox model showed that the predictors for OS were age, marital status, histopathology, differentiation and tumor node metastasis (TNM) stages, whether to undergo surgery and chemotherapy. However, the predictors for CSS were age, race, differentiation and TNM stages, whether to undergo surgery and radiation. The C-index for OS and CSS in the training set were 0.76 and 0.80. The AUC in the training set for 1-, 3- and 5-year OS and CSS were 0.84, 0.81, 0.80 and 0.88, 0.85, 0.83, respectively, which was similar in the validation set. The calibration curves showed good agreement between prediction and actual observations. DCA revealed that the nomogram had a better discrimination than TNM stages.

CONCLUSIONS

The nomogram showed accurate prognostic prediction in OS and CSS for vulvar cancer, which could provide guidance to clinical practice.

Assessing Rates of Positive Surgical Margins After Standard Excision of Vulvar Melanomas

BACKGROUND

Vulvar melanoma is a rare malignancy with frequent recurrence and poor prognosis. National guidelines recommend wide local excision of these tumors with allowances for narrower margins for anatomic and functional limitations, which are common on specialty sites. There is presently a lack of data of margin positivity after standard excision of vulvar melanomas.

OBJECTIVE

We aim to evaluate the rate of positive margins after standard excision of vulvar melanomas.

MATERIALS AND METHODS

Retrospective cohort study of surgically excised vulvar melanomas from the NCDB diagnosed from 2004 to 2019.

RESULTS

We identified a total of 2,226 cases. Across surgical approaches and tumor stages, 17.2% (Standard Error [SE]: 0.8%) of cases had positive surgical margins. Among tumor stages, T4 tumors were most commonly excised with positive margins (22.9%, SE: 1.5%). On multivariable survival analysis, excision with positive margins was associated with significantly poorer survival (Hazard Ratio 1.299, p = .015).

CONCLUSION

We find that positive margin rates after standard excision of vulvar malignancies are higher than for other specialty site melanomas. Our data suggest that use of surgical approaches with complete margin assessment may improve local control and functional outcomes for patients with vulvar melanoma as they have for patients with other specialty site melanomas.

Lymphatic mapping and sentinel node biopsy in vulvar melanoma: the first multicenter study and systematic review

OBJECTIVE

This multicenter study aimed to investigate the role of preoperative lymphatic mapping and sentinel node biopsy (SNB) as well as the impact of negative SNB on loco-regional control and survival in vulvar melanoma patients with clinically negative nodes (cN0).

METHODS

Patients who had a proven vulvar melanoma with a Breslow thickness of 1-4 mm, cN0 and underwent a preoperative lymphatic mapping followed by SNB between July 2013 and March 2021 were retrospectively included. Groin recurrence and mortality rate were calculated as absolute and relative frequency. Disease-free survival (DFS) and overall survival (OS) were assessed by the Kaplan-Meier method. We provided a systematic review, searching among PubMed/Medline and Embase libraries. A total of 6 studies were identified (48 patients).

RESULTS

A total of 18 women were included. Preoperative planar images showed 51 SNs in 28 groins. Additional SPECT/CT images were acquired in 5/18 cases; SNs were identified pre- and intra-operatively in all cases. A total of 65 SNs were excised from 28 groins. A total of 13/18 (72.2%) patients (21/28 groins, 75%) had negative SNs with no groin recurrences and 12/13 (92.3%) were still alive at last follow-up. Five out of the 18 (27.8%) patients (7/28 groins, 25%) had positive SNs, 2/5 (40%) patients died of cancer after 26.2 and 33.8 months, respectively. The median DFS and OS for the entire cohort were 17.9 months (95% CI, 10.3-19.9) and 65.0 months (95% CI, 26.2-infinite), respectively. The probability of DFS and OS at 3 years were 15.5% (95% CI, 2.6-38.7) and 64.3% (95% CI, 15.5-90.2), respectively.

CONCLUSIONS

The use of preoperative lymphatic mapping followed by SNB permits a precise and minimally invasive surgical approach in cN0 vulvar melanoma patients. Negative SNB is associated with low risk of groin relapse and good survival.

Effectual surgical perineal reconstruction of malignant mucosal vulvar melanoma

OBJECTIVE

To demonstrate a successful surgical treatment and reconstruction in a case of malignant mucosal vulvar melanoma.

CASE REPORT

A 52-year-old woman had stage II bulky malignant mucosal vulvar melanoma and received wide surgical excision with partial vulvectomy. She underwent 2-steps reconstructive vulvoplasty and vaginoplasty with skin grafting 1 year after initial surgical treatment. There was no evidence of recurrence after 3 years of follow-up.

CONCLUSION

Vulvar melanoma is a rare malignant neoplasm. Wide local excision with reconstruction can relieve pelvic discomfort and restore local function after the surgery.

Gynecologic tract melanoma in the contemporary therapeutic era: High rates of local and distant disease progression

BACKGROUND

Gynecologic tract melanoma (GTM) is a rare malignancy with historically poor outcomes. The current study examines patterns of care and oncologic outcomes in a large single-institution cohort from the contemporary therapeutic era.

METHODS

Patterns of care and predictors of outcomes were evaluated for all GTM patients without metastatic disease at diagnosis who were treated at our institution between 2009 and 2020 with >6 months of follow-up.

RESULTS

Of the 124 patients included, anatomic subsites were vulvar (n = 82, 66%), vaginal (n = 34, 27%), or cervical (n = 8, 6%). Primary tumor was resected for 85% (n = 106) with surgical nodal evaluation for 60% (n = 75). Systemic therapy, most commonly immune checkpoint inhibitors (ICI, 58% systemic therapy), was used to treat all except one unresectable patient (17/18) and 33% (35/106) of resectable patients. Seven patients received neoadjuvant ICI. Fourteen patients received adjuvant radiation therapy to the pelvis (RT, 13% of those undergoing resection). With a median follow-up of 45 months, 100 patients (81%) recurred. Four-year actuarial outcomes were: 46% local control, 53% nodal control, 36% distant metastasis-free survival, 17% disease-free survival, 49% melanoma-specific survival and 48% overall survival. Mitotic rate > 10/mm², nodal involvement and non-vulvar anatomic subsite were associated with poor outcomes. Patients treated after 2016 did not have significantly better outcomes than those treated earlier.

CONCLUSIONS

Patients with GTM continue to have poor outcomes in the contemporary therapeutic era with particularly notable poor local disease control relative to other mucosal melanoma subtypes. More effective oncologic therapy is needed.

Genitourinary melanoma: An overview for the clinician

Genitourinary (GU) melanoma is a rare presentation of melanoma accounting for approximately 0.5% of all melanomas. GU melanomas include primary melanomas of the vulva, vagina, uterine cervix, ovary, penis, scrotum, urethra, bladder, ureter, and kidney. These melanomas are often diagnosed in advanced stages and stigma is thought to contribute to delays in presentation. As the likely diagnosing provider, it is imperative that dermatologists, urologists, and gynecologists are aware of these uncommon sites of presentation. While there have been major advances in the treatment of melanomas as a whole in the last 10 years, their applications to GU melanomas have often been overlooked. GU melanomas have not been included in many of the major phase III clinical trials which brought contemporary advanced treatments to market and the prognoses for GU melanomas remain poor. Due to the rarity of GU melanomas, much of the literature provides generalized recommendations across multiple different organs affected by GU melanomas or omits certain topics, making it difficult to appreciate the fundamentals of the individual presentations. This review aimed to provide background information on the pathogenesis and epidemiology of the different sites of GU melanomas and categorize data specific to the presentation, staging, treatment, and prognosis of each type of GU melanoma to guide the clinician. It was also meant to encourage a multidisciplinary approach to the management of these patients as it spans the expertise of surgical oncologists, medical oncologists, radiation oncologist, dermatologists, urologists, and gynecologists.

SPTSSA Is a Prognostic Marker for Glioblastoma Associated with Tumor-Infiltrating Immune Cells and Oxidative Stress

Background. SPTSSA encodes the small subunit A of serine palmitoyltransferase. It catalyzes the formation of sphingoid long-chain base backbone of sphingolipids. Its role in glioma prognosis and tumor-infiltrating immune cells remains unclear. Methods. We analyzed SPTSSA expression and association with clinical prognosis using GEPIA and CGGA database. Then, GSEA was performed to identify relevant biological functions of SPTSSA. The correlations between SPTSSA expression and tumor immune infiltrates were investigated using CIBERSORT and TIMER. Finally, IHC and IF were performed to confirm the value of prognosis and the correlation with immune infiltration. Results. SPTSSA expression was significantly upregulated in diffuse glioma compared to normal tissues and associated with poor survival in GEPIA and CGGA database. Then, we identified biological processes and signaling pathways associated with SPTSSA expression. The result showed that SPTSSA enriched in the GO term like oxidative stress. Finally, we showed that SPTSSA expression was significantly associated with tumor-infiltrating immune cells and overall survival via IHC. Conclusion. These findings suggest that SPTSSA expression might be used as a prognostic biomarker for glioma and potential target for novel glioma therapy.

Chrysin Enhances Anti-tumor Immunity Response through IL-12-STAT4 Signal Pathway in B16F10 Melanoma Mouse Model

Chrysin (CHR) is a flavonoid with extensive pharmacological activity. The molecular formula of CHR is C₁₅ H₁₀ O₄ . CHR is reported to have antioxidative, anti-tumor and anti-viral functions. To evaluate its potential function as a vaccine adjuvant, we prepared a melanoma vaccine using a soluble protein extract of B16F10 melanoma cells as antigen and CHR as an adjuvant. The melanoma model was developed after two immunisations, and it was discovered that combining B16F10 soluble protein antigen-mixed CHR vaccine could inhibit tumor growth in the mouse model, and the overall survival rate was higher than that of the B16F10 antigen vaccine alone. In vivo and in vitro experiments were conducted to determine whether CHR functioned as an adjuvant by activating antigen-presenting cells (APCs). We discovered that CHR activated APCs both in vivo and in vitro and may enhance Th1 cell function by activating the IL12-STAT4 signal pathway, thereby enhancing the anti-tumor response of cytotoxic T lymphocytes (CTL) in vivo. Next, to verify the critical role of CD8⁺ T cells in suppressing melanoma development, we transplanted CD8⁺ T cells from immunised mice to B16F10 tumor-bearing mice and discovered that the survival rate of tumor-bearing mice was significantly prolonged. In summary, our experimental results indicate that CHR can be used as a potential adjuvant to enhance antigen immunogenicity, inhibit B16F10 tumor growth in mice and improve tumor immune response.

Multimodality Imaging and Genetics of Primary Mucosal Melanomas and Response to Treatment

Mucosal melanomas (MMs) are rare and aggressive tumors that arise from melanocytes in the mucosal tissues that line the respiratory, gastrointestinal, and urogenital tracts. Most MMs occur during the 6th and 7th decades of life. MMs may be asymptomatic but may also cause bleeding, pain, and itching, depending on the site of origin. Because of their asymptomatic or oligosymptomatic nature and the difficulty of visualizing them in some cases, they are often advanced tumors at patient presentation. MM staging varies depending on the site of the primary tumor. A simplified staging system allows classification of clinically localized disease as stage I, regional nodal involvement as stage II, and distant metastasis as stage III. MM differs genetically from its cutaneous counterparts. Common drivers in cutaneous melanoma such as B-raf proto-oncogene serine/threonine kinase (BRAF) have a lower mutation rate in MM, whereas mutations of other genes including the KIT proto-oncogene, receptor tyrosine kinase (KIT) and splicing factor 3b subunit 1 gene (SF3B1) are more common in MM. Complete resection is the best curative option. However, surgical intervention with wide local excision and negative margins may be difficult to attain because of the local anatomy and the extent of disease. In addition, despite aggressive surgical resection, most patients develop local recurrence and metastatic disease. Recent advances in the treatment of melanoma include immunotherapy and targeted therapy. Unfortunately, MMs have a relatively poor prognosis, with an overall 5-year survival rate of 25%. Online supplemental material is available for this article. ^©RSNA, 2021.

Management of Clitoral Melanoma Presenting as an Exophytic Clitoral Mass: A Case Report and Review of the Literature

Primary mucosal melanomas of the female genital tract account for one percent or less of all cases of melanoma with even fewer originating in the clitoris. Given the rarity of diagnosis of clitoral melanoma, there is a paucity of data guiding management. There is no supporting evidence that radical vulvectomy (with or without inguinal lymphadenopathy) is associated with improved disease-free or overall survival compared to partial vulvectomy or wide local excision. Additionally, there is no data to evaluate the role of sentinel lymph node biopsy or extensive lymphadenectomy in clitoral melanoma, however previous evidence demonstrates the utility of regional lymph node sampling in predicting survival in women with female genital tract mucosal melanoma. Adjuvant therapy considerations are often extrapolated from their use in treating cutaneous melanomas, including immune checkpoint inhibitors and other immunotherapy agents. Adjuvant radiation therapy has limited utility except in cases of bulky, unresectable disease, or when inguinal lymph nodes are positive for metastasis. The 52 year-old patient presented in this review was diagnosed with locally invasive advanced stage clitoral melanoma presenting as an exophytic clitoral mass. She underwent diagnostic primary tumor resection, which demonstrated ulcerative melanoma with spindle cell features extending to a Breslow depth of at least 28 mm. She subsequently underwent secondary wide local excision with groin sentinel lymph node biopsy, and adjuvant treatment with pembrolizumab. This article also emphasizes the importance of a multidisciplinary team involving gynecologic oncology, medical oncology, radiology, and pathology for management of this rare type of primary mucosal melanoma of the female genital tract.

Vulvar melanoma: an analysis of prognostic factors and treatment patterns

Objective

Melanoma comprises 5% to 10% of vulvar cancers and prognosis is poor. The purpose of this study was to identify prognostic factors and treatment patterns for vulvar melanoma using the National Cancer Database (NCDB).

Methods

The NCDB was queried for patients with invasive vulvar melanoma from 2004–2015. Descriptive statistics were generated to describe clinical and treatment details. Multivariable Cox regression and the Kaplan-Meier method were used to examine overall survival (OS).

Results

1,917 patients with vulvar melanoma met inclusion criteria. Median follow-up time was 32 months (range, 0–151 months). Older age, larger tumor size, advanced disease stage, increased Charlson-Deyo comorbidity score, and care at a non-academic center were independent predictors for decreased OS. Surgical management of the primary site, lymph node surgery, and insurance provided a significant survival benefit. Use of immunotherapy for vulvar melanoma has increased over time. Two-year OS with immunotherapy in patients with distant metastatic disease was higher, although this did not reach statistical significance (33% vs. 12%, p=0.054).

Conclusions

Vulvar melanoma has a poor prognosis for those with regional and distant metastatic disease. Extent of disease, tumor size, and patient age are important prognostic factors. Other favorable factors included insurance and surgical management. The use of immunotherapy has increased over time and may improve survival in those with distant disease. These data support further investigation into the role of immunotherapy for vulvar melanoma to optimize outcomes.

Management of Noncutaneous Melanomas

Noncutaneous melanomas are rare subtypes of melanoma with high rates of metastatic disease and poor overall survival. One-third to one-half of cases are amelanotic, which may contribute to a delay in diagnosis. Immunohistochemistry staining with typical melanoma markers helps confirm the diagnosis. There is no standard staging system across mucosal melanomas. Elective nodal dissection is not recommended and there is a paucity of data to support use of sentinel lymph node biopsy. Mutational analysis should be routinely performed. Systemic therapy options include targeted inhibitors, immunotherapy, and cytotoxic chemotherapy, although further studies are needed to confirm their efficacy.

Vulvar and Vaginal Melanomas-The Darker Shades of Gynecological Cancers

Melanomas of the skin are poorly circumscribed lesions, very frequently asymptomatic but unfortunately with a continuous growing incidence. In this landscape, one can distinguish melanomas originating in the mucous membranes and located in areas not exposed to the sun, namely the vulvo-vaginal melanomas. By contrast with cutaneous melanomas, the incidence of these types of melanomas is constant, being diagnosed in females in their late sixties. While hairy skin and glabrous skin melanomas of the vulva account for 5% of all cancers located in the vulva, melanomas of the vagina and urethra are particularly rare conditions. The location in areas less accessible to periodic inspection determines their diagnosis in advanced stages, often metastatic. Moreover, despite the large number of drugs newly approved in recent decades for the treatment of cutaneous melanoma, especially in the category of biological drugs, the mortality of vulvo-vaginal melanomas has remained almost constant. This, together with the absence of specific treatment guidelines due to the lack of a sufficient number of cases to conduct randomized clinical trials, makes melanomas with this localization a discouraging diagnosis, associated with a very poor prognosis. Our aim is therefore to draw attention to this oftentimes overlooked entity in order to encourage the community to employ various strategies meant to increase research in this area. By highlighting the main risk factors of vulvar and vaginal melanomas, as well as the clinical manifestations and molecular changes underlying these neoplasms, ideally novel therapeutic schemes will, in time, be brought into effect.

Surgical Management of Vulvar Melanoma: A Case Series

Vulvar malignant melanoma is the second most common subtype of vulvar cancer, accounting for 5-10% of all vulvar cancers. The prognosis is still very poor, although some advances have been achieved in the last years. One of the most significant changes in its management has been the development of less invasive surgical techniques that diminish the risk of postoperative morbidity and long-lasting sequelae. In this article, we review the surgical management of the pathology, based on the comment of 3 cases with vulvar melanoma treated at our institution.

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.

Development and validation of nomograms predicting cancer-specific survival of vulvar cancer patients: based on the Surveillance, Epidemiology, and End Results Program

OBJECTIVE

To explore potential prognostic factors and develop nomograms to predict the cancer-specific survival of patients with vulvar squamous cell carcinoma (SCC) and patients with vulvar melanoma.

METHODS

Cases of vulvar SCC and melanoma were retrieved from the Surveillance, Epidemiology, and End Results (SEER) Program, and randomly segregated into training and test sets. Based on the training set, univariate and multivariate Cox proportional hazard regressions evaluate the association between key demographic/clinical characteristics and vulvar cancer survival. Potential prognostic factors were included to construct nomograms for the prediction of 3-year and 5-year survival probabilities.

RESULTS

Age, tumor size, stage, surgery, and chemotherapy were potential factors associated with vulvar cancer survival. The C-indices for the training and test sets were 0.82 and 0.81 for SCC, and 0.73 and 0.70 for melanoma. Calibration curves revealed correlated agreements between nomogram-based probability and actual survival status.

CONCLUSION

Nomograms were developed to predict cancer-specific survival of patients with vulvar cancer, accordingly identifying the subgroup at high risk of cancer-specific mortality.

Cancer of the Vulva: A Review

BACKGROUND

Vulvar cancers, although rare, are becoming an increasingly serious threat to women's health. Cancer of the vulva accounted for 0.3% of all new cancers in the United States in 2019, with 6,070 newly diagnosed cases. This review details the epidemiology, pathogenesis, diagnosis, staging, and treatment of vulvar malignancies.

OBJECTIVE

To review cancer entities of the vulva, including vulvar intraepithelial neoplasms, squamous cell carcinoma (SCC), malignant melanoma, basal cell carcinoma, neuroendocrine tumors, and adenocarcinomas.

MATERIALS AND METHODS

Literature review using PubMed search for articles related to cancer of the vulva.

RESULTS

Vulvar intraepithelial neoplasms represent premalignant precursors to SCC of the vulva. There are several different histopathologic subtypes of SCC, and treatment is dependent on characteristics of primary tumor and lymph node involvement. Melanoma is the second most common cancer to affect the vulva, and staging is based on tumor, node, and metastatic spread.

CONCLUSION

Vulvar malignancies are rare, and diagnosis is dependent on biopsy and pathologic evaluation. Treatment for vulvar malignancies depends on histopathologic diagnosis but ranges from wide local excision with or without lymph node biopsy or dissection to radiation therapy with chemo- or immunotherapy. Overall survival varies by diagnosis.

Evaluation of treatment, prognostic factors, and survival in 198 vulvar melanoma patients: Implications for clinical practice

OBJECTIVE

To identify clinicopathological characteristics, treatment patterns, clinical outcomes and prognostic factors in patients with vulvar melanoma (VM).

MATERIALS & METHODS

This retrospective multicentre cohort study included 198 women with VM treated in eight cancer centres in the Netherlands and UK between 1990 and 2017. Clinicopathological features, treatment, recurrence, and survival data were collected. Overall and recurrence-free survival was estimated with the Kaplan-Meier method. Prognostic parameters were identified with multivariable Cox regression analysis.

RESULTS

The majority of patients (75.8%) had localized disease at diagnosis. VM was significantly associated with high-risk clinicopathological features, including age, tumour thickness, ulceration, positive resection margins and involved lymph nodes. Overall survival was 48% (95% CI 40-56%) and 31% (95% CI 23-39%) after 2 and 5 years respectively and did not improve in patients diagnosed after 2010 compared to patients diagnosed between 1990 and 2009. Recurrence occurred in 66.7% of patients, of which two-third was non-local. In multivariable analysis, age and tumour size were independent prognostic factors for worse survival. Prognostic factors for recurrence were tumour size and tumour type. Only the minority of patients were treated with immuno- or targeted therapy.

CONCLUSION

Our results show that even clinically early-stage VM is an aggressive disease associated with poor clinical outcome due to distant metastases. Further investigation into the genomic landscape and the immune microenvironment in VM may pave the way to novel therapies to improve clinical outcomes in these aggressive tumours. Clinical trials with immunotherapy or targeted therapy in patients with high-risk, advanced or metastatic disease are highly needed.

Construction and validation of a prognostic nomogram for primary vulvar melanoma: a SEER population-based study

BACKGROUND

Primary vulvar melanoma was an aggressive and poorly understood gynecological tumor. Unlike cutaneous melanoma, the incidence of vulvar melanoma was low but the survival was poor. There were no standard staging system and no census on treatment strategies of vulvar melanoma. Therefore, we aimed to conduct and validate a comprehensive prognostic model for predicting overall survival of vulvar melanoma and provide guidance for clinical management.

METHODS

Patients diagnosed with vulvar melanoma between year 2004 and 2015 from Surveillance, Epidemiology, and End Result (SEER) database were randomized to training cohort and validation cohort. Multivariate survival analysis was performed to screen for independent factors of survival. A nomogram was established to predict overall survival of vulvar melanoma. Receiver operating characteristic curve and calibration plot were performed to verify the discrimination and accuracy of the model. The decision curve analysis was performed to verify the clinical applicability of the model.

RESULTS

Total 737 patients with vulvar melanoma were randomized to the training cohort (n = 517) and the validation cohort (n = 220). Nomogram including age, race, tumor site, depth of tumor invasion, lymph node status, distant metastasis, tumor size, surgery, chemotherapy and radiotherapy was established and validated. The c-indexes for SEER stage, American Joint Committee on Cancer stage and this model were 0.561, 0.635 and 0.826, respectively. The high-risk group scored by this model had worse survival than the low-risk group (P < 0.001). Decision curve analysis revealed this model was superior in predicting survival.

CONCLUSIONS

Our model was deemed to be a useful tool for predicting overall survival of vulvar melanoma with good discrimination and clinical applicability. We hoped this model would assist gynecologists in clinical decision and management of patients diagnosed with vulvar melanoma.

Cold Atmospheric Pressure Plasma (CAP) as a New Tool for the Management of Vulva Cancer and Vulvar Premalignant Lesions in Gynaecological Oncology

Vulvar cancer (VC) is a specific form of malignancy accounting for 5–6% of all gynaecologic malignancies. Although VC occurs most commonly in women after 60 years of age, disease incidence has risen progressively in premenopausal women in recent decades. VC demonstrates particular features requiring well-adapted therapeutic approaches to avoid potential treatment-related complications. Significant improvements in disease-free survival and overall survival rates for patients diagnosed with post-stage I disease have been achieved by implementing a combination therapy consisting of radical surgical resection, systemic chemotherapy and/or radiotherapy. Achieving local control remains challenging. However, mostly due to specific anatomical conditions, the need for comprehensive surgical reconstruction and frequent post-operative healing complications. Novel therapeutic tools better adapted to VC particularities are essential for improving individual outcomes. To this end, cold atmospheric plasma (CAP) treatment is a promising option for VC, and is particularly appropriate for the local treatment of dysplastic lesions, early intraepithelial cancer, and invasive tumours. In addition, CAP also helps reduce inflammatory complications and improve wound healing. The application of CAP may realise either directly or indirectly utilising nanoparticle technologies. CAP has demonstrated remarkable treatment benefits for several malignant conditions, and has created new medical fields, such as “plasma medicine” and “plasma oncology”. This article highlights the benefits of CAP for the treatment of VC, VC pre-stages, and postsurgical wound complications. There has not yet been a published report of CAP on vulvar cancer cells, and so this review summarises the progress made in gynaecological oncology and in other cancers, and promotes an important, understudied area for future research. The paradigm shift from reactive to predictive, preventive and personalised medical approaches in overall VC management is also considered.

The role of sentinel lymph node mapping in lower genital tract melanoma

INTRODUCTION

Vulvar and vaginal melanomas are rare cancers of the female genital tract and account for 1% to 3% of all melanomas diagnosed in women. Due to the rarity of the disease, few data are available on the clinical and pathologic features of these cancers. Furthermore, treatment options are generally based on extrapolations of the information available for the more common cutaneous counterparts. Surgery represents the mainstay of treatment for lower genital tract melanoma. Moreover, the role of sentinel lymph node (SLN) assessment is controversial because no prospective data are available.

EVIDENCE ACQUISITION

Data were collected from Medline, Embase, Web of Sciences and Scopus databases. On July 10, 2020, we used the search comprising the terms "vulvar melanoma," "genital melanoma" and "vulvovaginal melanoma" including only studies in which SLN biopsy was performed.

EVIDENCE SYNTHESIS

Ten retrospective studies have been found. No randomized trials have been reported. The studies included 132 patients while only 63 (47%) undergone SLN. 99mTC with or without blue dye followed by ultrastaging was highly accurate and is currently the gold standard. Mean detection rate was 98.3%. No clear evidence supported the execution of back lymphadenectomy (after SLN mapping), in fact, extrapolating data from cutaneous melanomas of other sites, completion of lymphadenectomy does not confer a melanoma-specific survival advantage.

CONCLUSIONS

Although the small amount of available data, sentinel lymph node procedure is feasible and capable of identifying patients who have occult lymph node metastases. However, the potential role of the sentinel lymph node procedure as an alternative method of lymph node staging in patients with vulvar or vaginal melanoma needs further investigation.

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.

Recurrent Vulvar Melanoma – a Case Report

Melanoma rarely develops in the genital area. It is responsible for 5% of all vulvar malignancies. Postmenopausal women are usually more affected and the main differential diagnosis is vulvar melanosis and vulvar nevi. There are limited numbers of studies on dermoscopic features of mucosal melanoma, particularly early-stage lesions. Dermoscopic criteria have been described for the diagnosis of vulvar melanosis, and observational studies have been conducted to define the dermoscopic features of nevi and melanoma on the vulva. We are presenting the case of a 69-year old female with suspected recurrence of vulvar melanoma who previously had surgical removal of mucosal lentiginous melanoma on the left labia minor in June 2017. Five months after the primary melanoma surgery, the patient noticed de novo pigmentation at the left and right labia minor and urethral opening. On clinical examination, irregular light-brown pigmentation with ill-defined borders was evident on the labia minora of the vulva and around the external urethral orifice. On dermoscopy, irregular pigmented network, with white scar-like and structureless pinkish areas was evident. Incisional biopsy of the vulvar mucosa revealed melanoma in situ, confirming the local recurrence. CT scans of the head, thorax, abdomen and pelvis and gynaecological examination revealed no secondary deposits. Ultrasound of the regional inguinal lymph nodes revealed enlarged suspected pathologic involvement of the lymph nodes in both inguinal regions. Lymph node fine needle aspiration of lymph nodes in the left and right inguinal area revealed pleomorphic infiltrate of lymphoid cells with hemosiderin or melanoma pigment in the cytoplasm. Cystoscopic findings were within normal range. Interdisciplinary tumour board indicated wide excision of melanoma with margins of 1 cm and resection of the urethra, as well as biopsy of the enlarged left inguinal lymph node. Histopathological analysis of the resected mucosa revealed lentiginous spread of melanocytes showing moderate atypia, with focal pagetoid spread, without mitoses and ulceration and without invasion of lamina propria. The resection margins were tumour-free. Non-specific lymphadenitis was diagnosed on lymph node histopathological analysis. The patient was regularly monitored by a dermatologist and urologist, and had no recurrence. The accurate and prompt diagnosis is essential in the case of the vulvar melanoma which has unfavourable and unpredictable prognosis, with a tendency of local recurrences and regional and distant metastases in the case of invasive melanoma. In order not to miss early mucosal melanoma, dermatologists and gynaecologists should not avoid biopsy of lesions that demonstrate any clinical or dermoscopic feature of atypical melanocytic lesion, especially in case of the development of irregular pigmentation that expands and changes over time, the appearance of a solitary amelanotic papule or nodule requires excision or, in case of large diameter lesions, incision biopsies. Larger studies are needed to define more rigorously clinical and dermoscopic criteria that accurately distinguish early mucosal melanomas from benign skin lesions.

Diagnosis and management of vulvar cancer: A review

Vulvar malignancies represent a serious gynecologic health concern, especially given the increasing incidence over the past several decades. Squamous cell carcinoma and melanoma are common subtypes, although other neoplasms, such as basal cell carcinoma and Paget disease of the vulva, might be seen. Many vulvar cancers are initially misdiagnosed as inflammatory conditions, delaying diagnosis and worsening prognosis. It is essential that dermatologists are familiar with characteristic findings for each malignancy to ensure appropriate diagnosis and management. Herein, we review the unique epidemiologic and clinical characteristics of each major vulvar malignancy, as well as discuss their respective prognoses and current management recommendations.