Management of melanomas of the female genital tract

Amelanotic primary cervical malignant melanoma: A case report and review of literature

BACKGROUND

Primary malignant melanoma of the cervix (PMMC) is an extremely rare disease that originates from primary cervical malignant melanoma and frequently represents a challenge in disease diagnosis due to unclarified clinical and histological presentations, particularly those without melanin.

CASE SUMMARY

Here, we report a case of amelanotic PMMC, with a history of breast cancer and thyroid carcinoma. The patient was finally diagnosed by immunohistochemical staining and staged as IB2 based on the International Federation of Gynecology and Obstetrics with reference to National Comprehensive Cancer Network guidelines and was treated with radical hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. She then received combination therapy consisting of immunotherapy with tislelizumab and radiofrequency hyperthermia. She has remained free of disease for more than 1 year.

CONCLUSION

The differential diagnosis process reenforced the notion that immunohistochemical staining is the most reliable approach for amelanotic PMMC diagnosis. Due to the lack of established therapeutic guidelines, empirical information from limited available studies does not provide the rationale for treatment-decision making. By integrating 'omics' technologies and patient-derived xenografts or mini-patient-derived xenograft models this will help to identify selective therapeutic window(s) and screen the appropriate therapeutics for targeted therapies, immune checkpoint blockade or combination therapy strategies effectively and precisely that will ultimately improve patient survival.

Vulvar cancer incidence and net survival in Sweden 1960 to 2019: A population-based national study

INTRODUCTION

Vulvar cancer is a rare gynecological cancer affecting mostly older women. The aim of this population-based study was to investigate the incidence and net survival of vulvar cancer in Swedish women from 1960 to 2019.

MATERIAL AND METHODS

Data were retrieved from the mandatory Swedish Cancer Registry consisting of all women diagnosed with vulvar cancer between 1960 and 2019. Only women with a morphologically verified diagnosis of vulvar cancer were included. The individuals were then further matched with the Swedish Death Registry up until May 31, 2020.

RESULTS

In total, 8499 women were included with the following morphologies: squamous cell carcinoma 7250 (85.8%), malignant melanoma 539 (6.4%), adenocarcinoma 401 (4.8%) and other: 259 (3.1%). More than 50% of vulvar cancer cases occurred in women aged between 65 and 84 years of age. The 5-year age-standardized net survival increased from 53.0% (95% confidence interval [CI] 48.9-57.5) in 1960 to 72.1% (95% CI 68.8-75.5) in 2019. The proportion of adenocarcinoma among all cases increased from 2.0% to 8.7% between the 1960s and 2010s and an increase in age-standardized 5-year net survival was found for adenocarcinoma.

CONCLUSIONS

The age-standardized incidence of vulvar cancer cases in Sweden was stable between 1960 and 2019. During the study period, an increase in adenocarcinoma and a decrease in malignant melanoma cases was found. Five-year net survival increased by 20 percent units during the study period. For squamous cell carcinoma, an increased age-specific 5-year net survival was observed for all age groups, apart for women aged ≥85.

A rare synchronous presentation of primary malignant melanoma in cervix and vagina

ABSTRACT

Malignant melanoma, primarily a cutaneous malignancy, can also involve mucosal surfaces and constitutes 2% to 7% of all gynecological malignancies. Primary melanoma of the uterine cervix is an uncommon tumor and has poor prognosis. In the female genital tract, the synchronous occurrence of primary malignant melanoma in the cervix and vagina is rare. We report a case of a 48-year-old female patient who presented with a blackish vaginal mass and associated growth in the cervix. Biopsy from the vaginal mass was reported as malignant melanoma. Following this, she underwent radical surgery and adjuvant radiotherapy. After 12 months, the patient is doing well.

Primary Malignant Melanoma of the Cervix: An Integrated Analysis of Case Reports and Series

Melanoma, also known as malignant melanoma, is a type of malignant tumour that originates from melanocytes in the basal layer of the epidermis. Primary malignant melanomas of the female genital tract are rare. Similarly, primary malignant melanoma of cervix, which originates from cervical melanocytes, is an extremely rare disease and the second most common type of female melanoma in women aged between 15 to 44 years worldwide. To date, primary malignant melanoma of the cervix is characterized by poor patient prognosis and little consensus exists regarding the best treatment therapy. The situation is worsened by lack of clinical studies with large samples. Notably, surgery remains the preferred treatment option for patients with primary malignant melanomas of the cervix. Current treatments are based on Federation International of Gynecology and Obstetrics(2018) staging with reference to National Comprehensive Cancer Network guidelines. This study is in order to find a more suitable treatment modality for primary malignant melanoma of cervix. Therefore, we first conducted an integrated analysis of case reports and series to assess the impact of various factors on the prognosis of such patients. In summary, this is the first pooled analysis including 149 cases of primary cervical melanoma. We found that patients who underwent radical hysterectomy-based surgery, those with non-metastatic lymph nodes and those who underwent lymphadenectomy had significantly higher survival rates. In patients who had RH-based surgery, survival rates at the 24m time point of those who did not add other treatments was higher than those who did, but for those who had total hysterectomy-based surgery, the addition of other treatments to prolong median survival may be considered. In the overall analysis, age and lymphadenectomy were associated with increased and reduced risk of death in these patients, respectively. Although there is no statistical difference, stage III&IV, TAH, lymphatic metastases increase the risk of death; whereas radical hysterectomy was associated with reduced risk of death. In the subgroup analysis, for patients who have undergone radical hysterectomy-based surgery, lymphadenectomy reduces the risk of death, while lymphatic metastases and complementary other treatments increase the risk of death. For patients who have undergone total hysterectomy-based surgery, complementary treatment reduces the risk of death. In conclusion, via summarizing previous reports, the recommended treatment procedure for PMMC are radical hysterectomy and lymphadenectomy. The addition of other treatment options for patients who undergoing RH-based surgery need further study.

Immunotherapy combined with high- and low-dose radiation to all sites leads to complete clearance of disease in a patient with metastatic vaginal melanoma

A 73-year-old woman with metastatic vaginal mucosal melanoma that had progressed on ipilimumab and nivolumab experienced clinical and radiographic complete response to dual checkpoint inhibitor immunotherapy given in combination with high-dose plus low-dose radiation. General characteristics and treatment options in this disease are highlighted.

Primary Malignant Melanoma of the Cervix: A Case Report and a Review of the Literature

Background

Gynecologic melanomas are extremely rare malignancies, and primary malignant melanoma of the cervix (PMMC) is the rarest among them all, with less than 100 cases reported so far. Although some conditions have been correlated with the pathogenesis of this entity, no specific risk factor has been yet identified, with vaginal bleeding being the most common symptoms. The diagnosis is based on physical examination with speculum assessment and cytologic and histopathologic findings accompanied with immunohistochemical staining of lesion's biopsies. Case Presentation. We report a case of PMMC in a 34-year-old para-2 patient, among the youngest cases of PMMC reported, that presented to our clinic for routine examination. Gynecologic examination demonstrated a dark, heavily fully pigmented cervical growth completely covering the entire external cervical os. Biopsy obtained and showed malignant melanoma. She underwent radical hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. The pathological diagnosis was FIGO stage IB1 PMMC. Despite 2 courses of anti-PD-1 antibody (Nivolumab) treatment, the patient passed away 13 months after diagnosis (12 months after surgery).

Conclusions

Early diagnosis and subsequently early treatment are of high importance regarding patients' prognosis and survival. No standardized protocols or treatment guidelines specific for this rare cancer have been issued; thus, clinicians are called to assess each case individually. Current treatment options are based on surgical excision mostly with radical hysterectomy, but in advanced or recurrent state of the disease, other treatment modalities, such as chemotherapy, radiotherapy, and immunotherapy, can be employed. Prognosis for these patients is very poor, and survival rate remains extremely low, with the median OS reported being less than 2 years. Reporting and publishing of such cases are both of paramount importance for the better understanding of this uncommon cervical malignancy, and further biological and clinical investigations are required for more suitable and effective therapies to be determined. A new staging system, specific to PMMC, could be of great use for the better correlation of the disease's stage and prognosis of these patients.

Amelanotic Malignant Melanoma of the Male Urethra: A Potential Diagnostic Pitfall

A rare disease in an unusual site can closely mimic a typical presentation of a common disease, sometimes with devastating consequences. We present a case of primary amelanotic malignant melanoma of the urethra in a male, with clinical and histological characteristics that could have led to a mistaken diagnosis of high-grade urothelial carcinoma. Amelanotic mucosal melanoma should be suspected in all cases of high-grade mucosal tumors with practically any appearance (epithelioid, sarcomatoid, anaplastic, mixed). Morphological hints pointing toward melanoma-such as the presence of sparse melanin pigment or melanoma in situ-should be sought, and if absent, an immunohistochemical panel comprising S100 and HMB45 should be performed.

Primary amelanotic melanoma of the male urethra: A rare entity and diagnostic challenge

Malignant melanoma (melanoma) is a tumor of melanocytes that usually presents as cutaneous lesions. While melanoma can infrequently appear as a primary tumor elsewhere in the body, it is extremely rare in the urethra and even rarer as amelanotic malignant melanoma. We report the case of a 66-year-old male who presented with painless gross hematuria and lower urinary tract obstructive symptoms in the recent 2 weeks prior to his visit to our clinic. History and physical examination, including external genital examination, abdominopelvic sonography, and urine culture, were not conclusive. Cystourethroscopy revealed a creamy pink fragile mass located in the anterior proximal urethra that extended to the mid portion. Pathological examination of this lesion confirmed the diagnosis of amelanotic malignant melanoma using immunohistochemistry. Radical cystourethrectomy with ileal conduit was subsequently conducted. Although this tumor is extremely rare, urologists and pathologists should consider malignant melanoma as a diagnosis in patients with urethral tumor because of the likelihood of early metastasis and, consequently, poor prognosis. Complete surgical removal of the tumor and use of effective therapies can improve outcomes in these patients.

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.

Primary Cervical Malignant Melanoma: 2 Cases and a Literature Review

Primary cervical malignant melanoma (MM) is an extremely rare tumor, and we are only aware of 44 reported cases. Further information is needed with regard to this disease's clinicopathologic features. Two patients (55 and 81 yr old) with postmenopausal vaginal bleeding were diagnosed with primary cervical MM on the basis of hematoxylin-eosin staining and immunohistochemistry findings. Our literature review revealed that the average age in cases of primary cervical MM was 59 yr (range, 34-81 yr); 93% of patients presented with vaginal bleeding, and 82% of patients were diagnosed at an early clinical stage (International Federation of Gynecology and Obstetrics stages I-II). Primary cervical MM is an extremely rare cervical tumor and is associated with a poor prognosis. Histologic morphology and immunohistochemistry are very important considerations for diagnosing this disease, which must be differentiated from cervical undifferentiated carcinoma, leiomyosarcoma, and malignant peripheral schwannoma.

Female genitourinary tract melanoma: mutation analysis with clinicopathologic correlation: a single-institution experience

Female genitourinary tract melanoma (FGTM) is a rare and often-fatal form of mucosal melanoma. We describe our institutional experience with 55 cases of FGTM, 16 of which were evaluated with next-generation sequencing targeting 151 cancer-associated genes. Tumors tended to be thicker than conventional melanoma at presentation (median: 3.2 mm), were frequently ulcerated (50%), and characterized by incomplete initial resections. Regional lymph nodes showed tumor involvement at presentation in 28% of cases. With a median follow-up of 23.6 months, the median recurrence free survival was 14.5 months and the median overall survival was 29.6 months. Genomic analysis revealed mutually exclusive mutations in TP53 and KIT in 25%, while 19% of cases showed BRAF mutation. NRAS mutation was found in 13% of cases. Mutation in ATRX, previously undescribed in mucosal melanoma, was seen in three (10%) of 16 patients. Only invasive melanoma cases were included in statistical analyses. Patients with three or more mutations had marginally worse overall survival rates than those with two or less (P=0.07). Further studies are required for potential adjuvant treatment modalities to improve survival outcomes of FGTM.

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.

"Man in Istanbul" Lesions of the Urinary Tract (Known Entities in an Unusual Context): Melanoma, Carcinoid Tumors, Epithelioid Angiosarcoma

Certain tumors are more difficult to recognize when they present in an unusual location. Within the urinary tract, primary melanomas, carcinoid tumors, or epithelioid angiosarcoma could present diagnostic challenges due to their infrequent occurrence. This article emphasizes the clinical and histopathologic features of these entities and their differential diagnoses including the immunophenotype and their prognoses.

Isolated Urethral Metastasis From a Primary Ovarian Malignancy

BACKGROUND

Epithelial ovarian cancer (EOC) is the deadliest of gynaecological cancers, often manifesting itself at a later stage (stage 3 and 4). Metastases and recurrences tend to be limited to the abdominopelvic cavity, and cutaneous metastases are rare.

CASE SUMMARY

We report an interesting case of a 51-year-old who presented 2 years after her initial treatment with surgery and adjuvant chemotherapy for a stage IIB with an isolated recurrence in the external urethral meatus.

CONCLUSION

This case highlights the need for clinicians and patients to remain vigilant during follow-up visits to rule out recurrences despite nonspecific symptoms reported by patients.

Melanoma of the lower genital tract: Prognostic factors and treatment modalities

Primary melanomas originating from the gynecological tract are rare and aggressive cancers. The vulva is the most frequent site (70%), followed by vagina and more rarely by cervix. The clinical outcome of patients with female genital tract melanoma is very poor, with a 5-year overall survival (OS) of 37-50% for vulvar, 13-32% for vaginal, and approximately 10% for cervical melanoma. In this systematic review, we analyzed the pathogenesis and the different factors influencing the prognosis of melanomas of the lower genital tract, with particular emphasis on biologic variables that may influence new therapeutic approaches. We evaluated the different treatment modalities described in the literature, in order to offer a possible algorithm that may help the clinicians in diagnosing and treating patients with these uncommon malignancies.

A rare melanoma feature with primary ovarian origin: a case report and the literature review

Primary ovarian melanoma arising on a mature ovarian cystic teratoma is extremely rare. As best of our knowledge, to date, 49 cases have been reported in literature. Few information was reported about best management and therapy. We present a case occurred in a 69-year-old woman, without symptoms, who come to our unit for stress incontinence. A pelvic mass was detected and, after imaging evaluation, surgery was performed. The diagnosis was ovarian melanoma arose on a mature teratoma. No other adjuvant treatment was proposed after surgery. She died 9 months after the first diagnosis. Primary ovarian melanoma is a definite entity associated with a variable natural history and poor prognosis. Differential diagnosis is a challenge for the pathologist, because it must be differentiated by metastatic melanoma. The corner stone treatment of this disease is surgery; however, chemotherapy, immunotherapy, and target therapy seem to have a role.

Primary malignant melanoma of the female urethra: Report of a rare neoplasm of the urinary tract

INTRODUCTION

Melanoma is a malignant tumor that can affect any area of the anatomical economy. Its occurance in the female urethra is extremely rare. We report a case of primary malignant urethral melanoma developed in an elderly female patient.

PRESENTATION OF CASE

A 70 years old female presented with dysuria, poor stream, gross haematuria, intermittent blood spots, and a painful mass. On physical examination, there were no suspicious lesions on the skin. On external genital examination, a lesion at the level of the urethral meatus was observed. The mass was removed by wide local excision under spinal anaesthesia. The pathological diagnosis was malignant melanoma of the urethra.

DISCUSSION

The common presentations include bleeding and/or discharge per urethra, voiding dysfunction and the presence of tumor mass. Survival depends on the stage, location and size of the neoplasm at the time of diagnosis. Despite major surgery, radiotherapy or immunotherapy; malignant melanoma usually has a poor prognosis.

CONCLUSION

Melanoma of the female urethra is an extremely uncommon pathology leading to paucity of literature and any definite recommendations regarding management. The histological and immunohistochemical findings can be helpful in making an early and accurate diagnosis of malignant melanoma in the urogenital region.

Gynecologic melanomas: A clinicopathologic and molecular analysis

OBJECTIVE

Melanoma originating from gynecologic sites (MOGS), including the vulva, vagina, and cervix, is a rare and aggressive form of melanoma with poor long-term clinical outcome. The clinicopathologic features of vulvar and non-vulvar tumors remain relatively understudied, and in contrast to cutaneous melanomas at non-sun-exposed sites, MOGS typically do not harbor BRAF mutations. Thus, we sought to analyze the clinicopathologic and molecular features of MOGS.

METHODS

A large retrospective cohort of patients with MOGS (n=59) at a single large academic institution over a 28-year period was identified. Associations among clinicopathologic characteristics were assessed via standard statistical approaches, and clinical outcome was examined using Cox regression analysis. Sanger sequencing was utilized to identify mutations in hotspot regions of BRAF, KIT, NRAS, and CTNNB1.

RESULTS

Tumors involving the vagina and/or cervix (non-vulvar) are significantly associated with high-risk clinicopathologic features, including increased tumor thickness, ulceration, positive resection margins, lymph node metastasis, and poor long-term clinical outcome (with increased risk of death due to disease). The aggressive clinical behavior of non-vulvar tumors is independent of advanced clinical stage and lymph node metastasis in multivariate analysis. Targeted molecular analysis confirms an overall low rate of oncogenic mutations in our MOGS cohort, although KIT mutations (particularly in exon 11) are relatively enriched.

CONCLUSIONS

Overall, our results show that non-vulvar MOGS are aggressive tumors with poor long-term clinical outcome and indicate that few targeted therapeutic options are currently available to patients with MOGS.

Primary malignant melanoma of the cervix: Report of 14 cases and review of literature

PURPOSE

To investigate the clinical characteristics and prognosis of primary malignant melanoma of the uterine cervix.

RESULTS

The median age of the patients was 61.2 years (range, 42-78 years). The median overall survival of the patients at stage I, II and III were 39.2 months, 47.8 months and 9.0 months (P=0.574) and the 2-year overall survival for each stage were 80.0%, 50.0% and 0.0% respectively. Twelve (85.7%) patients developed recurrence and eleven patients (78.6%) died. Ten patients received surgery and four patients were treated with chemotherapy and/or radiotherapy. Immunotherapy was administrated to two patients after surgery. The mean survival time of patients with surgery and without surgery were 47.9 vs.7.75 months (P=0.047). Patients received radical hysterectomy had longer survival than patients underwent total hysterectomy (66.8 months vs 19.5 months, P=0.016).

METHODS

Clinical data from 14 patients with primary malignant melanoma of the cervix between January 1981 and December 2014 were reviewed.

CONCLUSIONS

Patients with primary malignant melanoma of the cervix have a poor prognosis. Radical hysterectomy and pelvic lymphnode dissection may offer better prognosis for stage I and II patients.

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.

Primary gynecologic melanoma: A report of two unusual cases

Background

Primary ovarian and cervical melanomas are extremely rare tumors with a poor prognosis. Diagnosis requires a high index of suspicion as presentation can mimic benign conditions clinically and other neoplasms histologically.

Cases

A 41 year-old with an adnexal mass underwent surgical staging for a stage IA ovarian melanoma. Imaging revealed a brain metastasis treated with radiation. Subsequent nodal recurrence was treated with immune and targeted therapies. She is alive with disease at 61 months follow-up. A 54 year-old presented after endocervical melanoma was diagnosed with polypectomy. She underwent radical hysterectomy, lymphadenectomy, and adjuvant brachytherapy. Immediate post-treatment imaging revealed widespread liver and pulmonary metastasis, currently being treated with ipilimumab.

Conclusion

Immunohistochemistry can facilitate the diagnosis of gynecologic melanoma, and multidisciplinary treatment is recommended.

•

Ovarian and cervical melanomas are rare tumors that present diagnostic challenges.

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Survival is poor, and multidisciplinary treatment is recommended.

•

Immunotherapy should be considered in the treatment of gynecologic melanoma.

Oncogenic mutations in melanomas and benign melanocytic nevi of the female genital tract

BACKGROUND

The genetic heterogeneity of melanomas and melanocytic nevi of the female genital tract is poorly understood.

OBJECTIVE

We aim to characterize the frequency of mutations of the following genes: BRAF, NRAS, KIT, GNA11, and GNAQ in female genital tract melanomas. We also characterize the frequency of BRAF mutations in female genital tract melanomas compared with melanocytic nevi.

METHODS

Mutational screening was performed on the following female genital tract melanocytic neoplasms: 25 melanomas, 7 benign melanocytic nevi, and 4 atypical melanocytic nevi.

RESULTS

Of the 25 female genital tract melanoma specimens queried, KIT mutations were detected in 4 (16.0%), NRAS mutations in 4 (16.0%), and BRAF mutations in 2 (8.0%) samples. Two of the tumors with KIT mutations harbored double mutations in the same exon. No GNAQ or GNA11 mutations were identified among 11 melanomas screened. BRAF V600E mutations were detected in 7 of 7 benign melanocytic genital nevi (100%) and 3 of 4 atypical genital nevi (75%).

LIMITATIONS

Our study is limited by the small sample size of this rare subset of melanomas.

CONCLUSION

KIT, NRAS, and BRAF mutations are found in a subset of female genital tract melanomas. Screening for oncogenic mutations is important for developing and applying clinical therapies for melanomas of the female genital tract.

[Melanomas of the female genital tract: state of the art]

Melanoma of the female genital tract is a rare location (less than 2% of melanomas all sites combined). These cancers have a very poor prognosis, due to the delay in diagnosis. Vulvar location is about 1% of melanomas then the vaginal location, uterine and ovarian. There is no consensus to date regarding their care, due to the rarity of the lesions. Their treatment must however be based on the current data concerning gynaecological cancers as well as standard management of cutaneous melanoma. The treatment is often based on conservative surgery, because radical resection does not improve survival. For the vulva and vagina, reconstructive surgery is possible. Treatment is sometimes supplemented by chemotherapy or radiotherapy, which could improve local control. The interest in the use of targeted therapy in these locations is not well known because of their rarity, but the study of genes c-Kit and BRAF provides new prospects for treatment. The objective of this review is to describe and report the current state of knowledge about gynaecologic melanomas.

A large retrospective multicenter study of vaginal melanomas: implications for new management

The outcome of patients presenting with vaginal melanoma has been assessed in a large multicentric retrospective study. The databases of 12 French institutions were searched for primary vaginal melanomas managed between 1990 and 2007. Among the 54 patients recorded, 46 were managed with a curative intent and included in the study. The clinical characteristics, treatments, and detection of c-KIT protein expression have been studied. The median age of the patients was 63.5 years (42-88). Twenty-eight patients were classified as International Federation of Gynecology and Obstetrics (FIGO) stage I, five as stage II, six as stage III, and one as stage IVA. c-KIT protein was overexpressed in 80% of the patients. Forty-two patients underwent surgical resection of the tumor, nine patients received local adjuvant treatment, and 10 received systemic adjuvant therapy. The median relapse-free survival was 10.9 months. c-KIT-negative status (P=0.01) and stage I (P=0.02) were associated with locoregional recurrence. The rate of metastasis was increased for advanced FIGO stages (P<0.01). The median overall survival (OS) was 28.4 months. The finding of lymph node metastasis adversely affected OS (P<0.01). Conservative surgery and radiotherapy were associated with a decrease in metastasis-free and OS (P<0.01) compared with surgery alone, this group of patients presenting with advanced FIGO stages (P=0.02). Despite the use of limited data, conservative surgery combined with a sentinel lymph node procedure, followed by adjuvant radiotherapy could be proposed to patients with early FIGO stage in the absence of validated management. c-KIT negativity by immunochemistry appears to be a poor prognosis marker in terms of locoregional recurrences but not for metastatic spread nor survival. Further assessment of the role of c-KIT expression in this disease is thus mandatory to select patients for targeted therapy.

Primary Malignant Melanoma of the Vagina: A Retrospective Clinicopathologic Study of 44 Cases

Objective

This study aimed to identify prognostic factors of survival and improve treatment strategies in women diagnosed with primary malignant melanoma of the vagina.

Methods

Between December 2002 and August 2011, 44 patients with lesions confined to the vagina and diagnosed with melanoma at Fudan University Shanghai Cancer Center were evaluated retrospectively. Prognostic factors were analyzed by Kaplan-Meier method.

Results

With a median follow-up time of 18.9 months (range, 6.0–94.3 months), 30 (68.2%) patients developed recurrences, whereas 21 (47.7%) died of disease. Median progression-free survival (PFS) was 14.4 months and median overall survival (OS) was 39.5 months. Depth of invasion (DOI) was significantly associated with OS (P = 0.023), and there was an obvious tendency toward improved OS with a negative lymph node status (P = 0.063). The DOI was significantly associated with lymph node status (P = 0.047). The extent of surgery (wide local excision vs radical excision) was not associated with differences in PFS or OS (P = 0.573 and P = 0.842, respectively). Longer PFS was observed in patients who received adjuvant chemotherapy and radiotherapy (P = 0.038).

Conclusions

The prognosis of primary vaginal melanoma is dependent on the DOI and lymph node status in our study. Surgical resection of disease, especially wide local excision, should be considered as the optimal treatment when complete removal of tumor with a negative margin is possible. Adjuvant therapy may be associated with a longer PFS.

Primary malignant melanoma of the female urethra

We report here on a rare case of primary malignant melanoma of the female urethra. A 69-year-old female presented at our hospital with a several month history of dysuria, poor stream, gross hematuria, intermittent blood spots, and a painful mass at the external urethral meatus. The physical examination revealed a soft, small, chestnut-sized lesion through the urethral orifice. The mass was tan colored, ulcerated, covered with necrotic tissue, and protruded from the external urethral meatus. The mass was removed by wide local excision under spinal anesthesia. The pathological diagnosis was malignant melanoma of the urethra. Computed tomography of the abdomen as well as a whole-body bone scan showed no evidence of metastasis. The patient has been free of disease for 6 months postoperatively. We discuss the clinicopathologic features and treatment of this tumor.

A literature overview of primary cervical malignant melanoma: an exceedingly rare cancer

Primary malignant melanoma (MM) of the uterine cervix is an extremely rare neoplasm, with about 78 cases described in the literature. Since traces of melanocytes in normal cervical epithelium were found in 3.5% of cases primary origin of melanoma at this site cannot be ruled out. It occurs mainly in the sixth decade of life, and it is five time less common than primary vaginal or vulvar MM. Clinical history usually includes abnormal genital bleeding; and physical examination frequently reveals a pigmented, exophytic cervical mass. Diagnosis is confirmed by immuno-histochemical methods and by exclusion of any other primary site of melanoma. Treatment of this condition is not yet standardized, and the overall prognosis is very poor. Diagnostic approaches and therapeutic procedures on primary MM of the uterine cervix are discussed following a review of the literature encompassing more than one century.

Primary melanoma of the vagina. A clinical case

Primary melanoma of the vagina is a rare neoplasm that appears in the 6(th) and 7(th) decades of life. It has a poor prognosis, for which there is no consensus regarding treatment; indeed, the literature describes a number of therapeutic options. This paper describes a patient with vaginal melanoma treated by local excision and immunotherapy.

Massive intra-abdominal undifferentiated carcinoma derived from an endometrioid adenocarcinoma in a "normal-sized" ovary

We report a case of massive intra-abdominal undifferentiated carcinoma derived from a tiny well-differentiated endometrioid adenocarcinoma of the ovary. The patient, a 56-year-old woman, who presented with a large intra-abdominal mass, underwent cytoreductive surgery with hysterectomy and bilateral salpingo-oophorectomy. Macroscopically, the intra-abdominal mass was composed of fragile and solid tumor components with extensive necro-hemorrhagic areas, mimicking a primary peritoneal tumor. Both ovaries were apparently normal in size, but a cut section of the right ovary revealed a 2-cm solid and cystic tumor showing focal rupture to the peritoneal surface. The intra-abdominal tumor consisted of pleomorphic cells without specific differentiation, showing diffuse sheet-like proliferation. The right ovarian tumor was a histologically well-differentiated endometrioid adenocarcinoma. Both the intra-abdominal undifferentiated tumor and the ovarian adenocarcinoma cells were immunohistochemically positive for keratin AE1/3, Ber-EP4, and CD10. Epithelial membrane antigen was positive only in the ovarian adenocarcinoma component, and vimentin was diffusely positive only in the intra-abdominal undifferentiated tumor component. Calretinin was negative in both tumor components. Allelotype analysis using 24 polymorphic markers located on 12 chromosomal arms showed that the intra-abdominal undifferentiated carcinoma and ovarian adenocarcinoma components had a high concordance rate (88%) of allelic patterns including identical allelic loss patterns at 7 chromosomal loci, suggesting a common genetic lineage. These data suggest that ovarian endometrioid adenocarcinoma, even when small in size, can give rise to a massive undifferentiated carcinoma filling the peritoneal cavity.

Management of mucosal melanomas of the head and neck: did we make any progress?

PURPOSE OF REVIEW

Primary mucosal melanoma of the head and neck is a rare tumor associated with a poor outcome. This diagnosis carries a great deal of anxiety for the patients and puts the clinician in a predicament to find concise and reliable information for adequate risk stratification and treatment.

RECENT FINDINGS

Sinonasal mucosal melanomas should be staged according to the tumor node metastasis staging system and could be treated endoscopically with similar results to open surgery. Prophylactic neck dissection could be indicated in oral melanomas, given their tendency to regional failure. Adjuvant radiotherapy improves locoregional control in several series but does not improve survival. Definitive radiation with high linear energy transfer modalities achieves locoregional control rates comparable to surgery. Biochemotherapy improves survival in mucosal melanoma of the head and neck and should be considered for patients with metastatic or extensive locoregional disease.

SUMMARY

The standard therapy for melanoma continues to be surgical resection, possibly associated with adjuvant radiation. Biochemotherapy should be considered for bulky metastatic disease. In the future, definitive radiation regimes, molecular staging and targeted therapy may play a major role.

Surgical management of primary disease

Despite advancements in the treatment of melanoma, surgical management remains the cornerstone for treatment and long-term survival. The authors present their surgical approach to the patient with melanoma including evaluation, treatment, and reconstruction. In addition, management of melanoma occurring in difficult anatomic areas and in special patient populations is reviewed.

Unexpected Long Survival in Primary Malignant Melanoma of the Male Urethra

A case of primary malignant melanoma of the urethra in a 60-year-old male is presented. Despite multiple adverse prognostic factors and against expectations, after a follow-up of 5.5 years he is still alive.