Vulvar melanoma, biologically different from other cutaneous melanomas

Multimodality treatment of a primary vulvar melanoma in a low resource setting: A case report

Primary vulvar melanoma is a rare but highly aggressive malignant neoplasm accounting for 1-2 % of all malignant melanoma and 5-10 % of all vulvar cancers in females. Here we report a case of 32 years old female diagnosed with primary vulvar melanoma during the evaluation of a two cm growth in the inner labia minora on the right side. She underwent wide local excision with excision of the distal one cm of the urethra and bilateral groin node dissection. The final histopathology was vulvar malignant melanoma with 1 out of 15 groin nodes involved but all resected margins were free of tumor. The final surgical stage was T4bN1aM0 (8th AJCC TNM) and IIIC (FIGO). She received adjuvant radiotherapy followed by 17 cycles of Pembrolizumab. To date, she is both clinically and radiologically disease free with a progression-free survival of 9 months.

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.

Primary malignant melanoma of the female genital tract synchronously involving the vulva and uterine cervix: A case report

RATIONALE

Primary melanomas of the female genital tract are rare and usually occur in the vulva and vagina. Involvement of the cervix, uterus, and ovary are extremely rare. Surgery and adjuvant therapy remain the mainstay of treatment. The majority of patients experience poor long-term survival. This report aimed at highlighting an extremely rare case of primary melanoma of the female genitalia, synchronously involving the vulva and uterine cervix.

PATIENT CONCERNS

A 58-year-old multiparous female presented with postmenopausal bleeding for 10 days.

DIAGNOSES

Speculum examination and histologic analysis of the surgical specimens revealed synchronous involvement of the vulva and uterine cervix by malignant melanoma. According to the American Joint Committee on Cancer stage grouping for melanoma, this tumor was at stage V.

INTERVENTIONS

The patient subsequently underwent radical surgery and postoperative chemotherapy.

OUTCOMES

She has been on regular follow-up, and is now free of disease for 50 months after the operation.

LESSONS

Primary melanomas of the female genital tract have biologically aggressive characteristics. Optimal management consists of individualized surgery and adjuvant therapy. However, early recognition and prompt intervention offer maximal benefit from treatment.

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.

Label-Free Imaging of Female Genital Tract Melanocytic Lesions With Pump-Probe Microscopy: A Promising Diagnostic Tool

We analyze vulvar melanomas using an emerging optical molecular imaging technique called pump-probe microscopy. The method may improve the diagnosis and staging of vulvar melanomas. Supplemental digital content is available in the text.

Objectives

Melanomas of the female genital tract present a unique clinical challenge. Not only are these lesions in an anatomically sensitive area, but also they tend to be multifocal and have high recurrence rates. Furthermore, several benign melanocytic proliferations resemble early-stage melanoma clinically and/or histopathologically. Thus, there is a significant need for additional tools that can help correctly diagnose and stage these lesions. Here, we quantitatively and nondestructively analyze the chemical composition of melanin in excised pigmented lesions of the female genital tract using pump-probe microscopy, a high-resolution optical imaging technique that is sensitive to many biochemical properties of melanin.

Materials and Methods

Thirty-one thin (~5 μm) tissue sections previously excised from female genital tract melanocytic lesions were imaged with pump-probe microscopy and analyzed.

Results

We find significant quantitative differences in melanin type and structure between melanoma and nonmalignant melanocytic proliferations. Our analysis also suggests a link between the molecular signatures of melanins and lesion-specific genetic mutations. Finally, significant differences are found between metastatic and nonmetastatic melanomas. The limitations of this work include the fact that molecular information is restricted to melanin pigment and the sample size is relatively small.

Conclusions

Pump-probe microscopy provides unique information regarding the biochemical composition of genital tract melanocytic lesions, which can be used to improve the diagnosis and staging of vulvar melanomas.

Early diagnosis of genital mucosal melanoma: how good are our dermoscopic criteria?

Background

There are limited studies on the dermoscopic features of mucosal melanoma, particularly early-stage lesions. Described criteria include the presence of blue, gray, or white colors, with a reported sensitivity of 100%. It is unclear if these features will aid in the detection of early mucosal melanoma or improve diagnostic accuracy compared to naked-eye examination alone.

Case

An Asian female in her fifties was referred for evaluation of an asymptomatic, irregularly pigmented patch of the clitoral hood and labia minora of unknown duration. Her past medical history was notable for Stage IV non-small cell lung cancer. She denied a personal or family history of skin cancer. Dermoscopic evaluation of the vulvar lesion revealed heterogeneous brown and black pigmentation mostly composed of thick lines. There were no other colors or structures present. As the differential diagnosis included vulvar melanosis and mucosal melanoma, the patient was recommended to undergo biopsy, which was delayed due to complications from her underlying lung cancer. Repeat dermoscopic imaging performed three months later revealed significant changes concerning for melanoma, including increase in size, asymmetric darkening, and the appearance of structureless areas and central blue and pink colors. Histopathological examination of a biopsy and subsequent resection confirmed the diagnosis of melanoma in situ.

Conclusion

Previously described dermoscopic features for mucosal melanoma may not have high sensitivity for early melanomas. Additional studies are needed to define the dermoscopic characteristics of mucosal melanomas that aid in early detection. Health care providers should have a low threshold for biopsy of mucosal lesions that show any clinical or dermoscopic features of melanoma, especially in older women.

Analysis of non-squamous vulvar cancer cases: A 21-year experience in a single center

Objective:

To evaluate the patients with non-squamous cell type of vulvar cancer who were treated in our clinic within 21 years.

Materials and Methods:

We assessed the data of 14 patients who were treated for non-squamous cancer of the vulva between January 1992 and August 2013. The age of patients, histopathological diagnosis of the tumor, tumor size, tumor location, medical or surgical treatment, response to the treatment, recurrence, and survival rates were analyzed.

Results:

The mean age of the patients was 53 years. The main complaint was vulvar pruritus (71%). Mean tumor size was 2.4 cm (range: 0.5-6 cm). In 65% of cases, the tumor was localized in the labia majora. The histopathologic diagnosis of the patients was as follows: malignant melanoma in 5 patients, basal cell carcinoma in 5 patients, mucinous type adenocarcinoma in 2 patients, apocrine gland carcinoma in one patients, and malign peripheral nerve sheath tumor in 1 patient. For 11 patients, surgery was the primary treatment. Radical vulvectomy and bilateral inguinofemoral lymphadenectomy were performed in 8 patients. Local excision alone without lymphadenectomy was performed in other 3 patients. Five of eight patients (62.5%), who undergone radical surgery, had lymph node metastases. Of these 5 patients, two had bilateral lymph node metastasis. Mean follow-up time was 49.2 months (range 12 to 72 months). Eight (57.1%) patients had suffered first recurrence. In those patients, the mean time to recurrence was 19.5 months (range, 6-48 months).

Conclusion:

Non-squamous cell vulvar cancer is a rare disease and comprises a heterogeneous group of tumors. Malignant melanoma is the most aggressive one. Multicenter prospective studies are necessary in order to standardize the treatment of these rare tumors.

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.

Utility of sentinel node biopsy in vulvar and vaginal melanoma: report of two cases and review of the literature

Sentinel node (SN) biopsy is widely applied for treatment planning of cutaneous melanoma. However, using this strategy in female lower genital tract tumors has not yet been established. We report two cases, one each of vulvar and vaginal melanoma who underwent SN biopsy and review the available literature. Our experience and available limited evidence suggests that this low morbidity technique can be used for obtaining prognostic information and hence treatment planning for this disease. However, a false negative rate perhaps in the order of 15% suggests that careful consideration is necessary before using sentinel lymph node biopsy in the management of vulvar and vaginal melanoma.

Population-based incidence rates of malignant melanoma of the vulva in Germany

OBJECTIVES

Only few population-based incidence analyses of vulvar melanoma including the United States and Sweden are currently available. We studied the incidence of vulvar melanoma in a large population-based cancer registry of East Germany and compared our findings with the United States and Sweden.

METHODS

We extracted vulvar melanoma registered between 1976 and 1989 in the former National Cancer Registry of the German Democratic Republic (GDR) and of three new East German cancer registries of the federal states of Sachsen, Brandenburg, and Mecklenburg-Vorpommern of the period 1998 to 2002. We calculated age-specific and age-standardized incidence rates using the World Standard Population.

RESULTS

One hundred two cases (1976-1989, former GDR) and twenty-five cases of vulvar melanoma (1998-2002, three new federal states) were registered. The age-standardized incidence rate (World Standard Population) remained constant over the period from 1976 to 1989 and ranged between 0.26 and 0.52 cases per million. From 1998 to 2002, the incidence rate was 0.48 per million. The ratio of registered vulvar melanoma to skin melanoma was 1:71, and the ratio of vaginal melanoma to skin melanoma was 1:314. Age at diagnosis during the period 1976 to 1989 was lower among women with vulvar melanoma (median age 70 years) compared to women with vulvar tumors other than melanoma (median age 73 years).

CONCLUSIONS

The risk of vulvar melanoma was considerably lower in East Germany than in the United States and Sweden. Due to the rarity of vulvar melanoma, population-based cancer registries are hampered to study this tumor in detail.

Pigmented seborrheic keratoses of the vulva clinically mimicking a malignant melanoma: a clinical, dermoscopic-pathologic case study

The diagnosis of seborrheic keratosis is, in general, a clinical one, but in some cases, the differential diagnosis between pigmented seborrheic keratosis and malignant melanoma is difficult. Dermoscopy may improve the early diagnosis of vulvar melanoma and thus play a role in the preoperative classification of pigmented lesions at this particular site. We report the first case of a pigmented seborrheic keratosis of the vulva clinically mimicking a malignant melanoma, whose dermoscopic features have been investigated together with their pathologic correlates. Dermoscopically our case shows the absence of comedo-like openings and the presence of the pseudo-network. Dermoscopy is therefore a useful method for the differential diagnosis of pigmented lesions even in the vulva.

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.

Vulvar melanoma: diffuse melanosis and metastasis to the placenta

Mucocutaneous melanoma, including vulvar melanoma, is rare and has a worse prognosis and higher recurrence rate than traditional cutaneous melanoma. Diffuse cutaneous melanosis is another rare clinical presentation of metastatic melanoma. It is essential for dermatologists to be alerted to rare presentations of melanoma, to facilitate early detection. We present the first case to our knowledge of metastatic vulvar melanoma with diffuse cutaneous melanosis in a pregnant young woman. Despite the occurrence of placental metastasis, a healthy, unaffected baby was born. This case exemplifies the aggressiveness of vulvar melanoma. The genitalia should be included in routine total body skin examinations. Pregnant women with generalized melanosis may be at increased risk for placental metastasis of melanoma. Pregnancy does not alter the incidence or prognosis of melanoma; however, patients with a poor prognosis or high recurrence risk should be informed of potential pregnancy complications associated with melanoma recurrence or metastasis.

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 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).

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.