Vulvar Melanoma Associated with Lichen Sclerosus in a Child: Case Report and Literature Review

EuroGuiderm guideline on lichen sclerosus-introduction into lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness. It may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are redness and oedema, typically followed by whitening of the genital skin; sometimes fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS, highlight important aspects in the care of LS patients (part 1), generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

A Pigmented Lesion of the Vulva Revealing Aggressive Melanoma: A Case Report

Vulvar melanoma (VM) is a rare and aggressive malignancy presenting unique challenges in diagnosis and management. This report presents the case of a 61-year-old female patient and explores the clinical characteristics, diagnostic modalities, treatment strategies, and prognosis associated with VM. The patient presented with a painless mass on the labia majora, which turned out to be an undifferentiated malignant tumor process consistent with melanoma on examination. Immunohistochemical analysis confirmed the diagnosis and subsequent imaging revealed metastatic disease necessitating palliative chemotherapy following radiotherapy. VM is a rare and aggressive form of melanoma. While surgery is the standard of care for early stages, advanced stages require a combination of immunotherapy and targeted treatments. Clinical trials are vital to improve our understanding of this condition and the various aspects of its care. Collaboration among experts is essential to achieve progress in managing these patients.

Melanoma in children: A systematic review and individual patient meta-analysis

The current evidence on paediatric melanoma is heterogeneous, especially regarding the prognosis of different histological subtypes. We sought to systematically review the evidence on paediatric melanoma, highlighting the major sources of heterogeneity and focusing on available data on single patients. A systematic search was performed from 1948 to 25 January 2021. Only studies reporting at least one case of cutaneous melanoma in patients aged ≤18 years were included. Unknown primary and uncertain malignant melanomas were excluded. Three couples of authors independently performed title/abstract screening and two different authors reviewed all the relevant full texts. The selected articles were manually cross-checked for overlapping data for qualitative synthesis. Subsequently data on single patients were extracted to perform a patient-level meta-analysis. PROSPERO registration number: CRD42021233248. The main outcomes were melanoma-specific survival (MSS) and progression-free survival (PFS) outcomes. Separate analyses were done of cases with complete information on histologic subtype, focusing on superficial spreading (SSM), nodular (NM) and spitzoid melanomas, as well as of those classified as de-novo (DNM) and acquired or congenital nevus-associated melanomas (NAM). The qualitative synthesis covered 266 studies; however, data on single patients were available from 213 studies including 1002 patients. Among histologic subtypes, NM had a lower MSS than both SSM and spitzoid melanoma, and a lower PFS than SSM. Spitzoid melanoma had a significantly higher progression risk than SSM and trended toward lower mortality. Focusing on nevus-associated status, DNM demonstrated better MSS after progression than congenital NAM, and no differences were highlighted in PFS. Our findings describe the existence of different biological patterns in paediatric melanoma. Specifically, spitzoid melanomas demonstrated intermediate behaviour between SSM and NM and showed a high risk of nodal progression but low mortality. This raises the question of whether spitzoid lesions are being over-diagnosed as melanoma in childhood.

Genital lichen sclerosus and melanoma; a systematic review

Background

Lichen sclerosus (LSc) is a chronic, inflammatory, destructive skin disease with a predilection for the genitalia (GLSc). An association with vulval (Vu) and penile (Pe) squamous carcinoma (SCC) is now well established but melanoma (MM) has only rarely been reported complicating GLSc.

Methods

We have performed a systematic literature review of GLSc in patients with genital melanoma (GMM). Only articles that mentioned both GMM and LSc affecting either the penis or vulva were included.

Results

Twelve studies with a total of 20 patients were included. Our review shows that an association of GLSc with GMM has been more frequently reported in women and female children than men viz, 17 cases compared with three. It is notable that five of the cases (27.8%) concerned female children aged under twelve.

Discussion

These data suggest a rare association between GLSc and GMM. If proven, there arise intriguing questions about pathogenesis and consequences for counselling of patients and follow-up.

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

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

Comparison of lichen sclerosus in boys and girls: A systematic literature review of epidemiology, symptoms, genetic background, risk factors, treatment, and prognosis

BACKGROUND

Studies concerning pediatric lichen sclerosus are limited, and, to date, there have been no studies comparing the course of lichen sclerosus in boys and girls. We sought to examine all publications on boys and girls with lichen sclerosus and assess and compare epidemiology, symptoms and signs, genetic background, risk factors, treatment, and prognosis.

METHODS

A systematic search was performed in the Embase, Medline, Cochrane, and Web of Science databases. Inclusion criteria were information on children ages 0-18 years and a clinical or histologic diagnosis of lichen sclerosus. Literature from 1985 to 2021 was reviewed.

RESULTS

A total of 1780 articles were retrieved from the search, of which 90 articles were eligible for inclusion. Boys and girls present similarly on many aspects; nonetheless, treatment and follow-up are approached differently.

CONCLUSIONS

Though the clinical approach is often different, lichen sclerosus in boys and girls demonstrates many similarities. More research is needed, especially on follow-up, to gain a better understanding of the course of lichen sclerosus and establish an advanced management plan for children.

Does compliance to topical corticosteroid therapy reduce the risk of development of permanent vulvar structural abnormalities in pediatric vulvar lichen sclerosus? A retrospective cohort study

BACKGROUND

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis of the genital skin, with up to 20% of cases in the pediatric age group. Limited data exist concerning the prognosis of pediatric VLS, particularly the likelihood of permanent architectural change and whether this can be prevented by compliance with topical corticosteroid treatment (TCS).

OBJECTIVE

To evaluate the extent to which compliance to TCS treatment influences the risk of developing vulvar structural abnormalities, including clitoral phimosis and diminutive or fused labia minora.

METHODS

A retrospective chart review of case records of pediatric-age females with VLS between January 31, 2004 and January 31, 2021.

RESULTS

One hundred eighteen cases of VLS were identified, with a mean age at diagnosis of 7.25 years and a mean follow-up period of 42.7 months. Thirty-four girls were "partially compliant," whereas 84 were "compliant." The risk ratio (RR) of developing any vulvar structural abnormality or clitoral phimosis was 5.76 (95% CI 2.96-11.3) and 21.2 (95%CI 5.23-85.9) times higher, respectively, in partially compliant compared with compliant subjects. The RR of a partially compliant female with pre-pubertal onset VLS having a vulvar structural abnormality persisting beyond menarche was increased 3.54-fold relative to compliant females (95% CI 1.75-7.17).

LIMITATIONS

The retrospective nature of our data, lack of a control group, wide variability in follow-up duration, and nonstandardized method of stratifying compliance.

CONCLUSION

Vulvar structural abnormalities are common in prepubertal onset VLS. Compliance to TCS appears to be critical in the prognosis of pediatric VLS although attitudes underpinning noncompliance to TCS treatment require further elucidation.

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

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

[Paediatric vulval clinic]

In 2008 a vulval clinic was established at the University Clinic of Schleswig Holstein, Campus Luebeck, Department of Dermatology. A total of 1227 patients were referred to the clinic between 2008 and October 2020, including 91 children (age range 1-13 years) and 17 adolescents (age range 14-17 years). The most common paediatric vulval conditions encountered were lichen sclerosus (33%), vulvitis (23%) and vulval psoriasis (7%). Quality of life was measured in 81 children using the paediatric version of the Dermatology Life Quality Index (DLQI). Of a maximum 30 points, the mean score was 7.2, confirming the association between vulval diseases and impaired quality of life in children and adolescents.

Pediatric vulvar malignancies: rare but important to know

Malignancies of the vulva in the pediatric population are exceptionally rare, which makes it difficult to gain any insight into their clinicopathologic profile. In this review, we summarize all published cases of a vulva malignancy in pediatric patients (≤21 years) reported in the English language literature for the 50-year period between 1970 and 2020. We estimate that less than 100 malignancies have been reported in total, approximately 50% of which were rhabdomyosarcomas. Invasive squamous cell carcinomas, yolk sac tumors, Ewing sarcoma/primitive neuroectodermal tumors (ES/PNET) and melanomas each represented approximately 10% of reported cases. For rhabdomyosarcoma, the alveolar and embryonal subtypes were reported with equal frequency, with both representing 70% of cases combined. The average patient age was 9.8 years. 48% and 35% were Intergroup Rhabdomyosarcoma Study clinical groupings I and III respectively. Managements were generally multimodal, and overall outcomes for the group were favorable. For invasive squamous cell carcinoma, the patients were all in their teenage years, with an average age at diagnosis of 15.2 years. A small subset of cases were associated with human papillomavirus and immunosuppression, and it is possible that immunosuppression has a role in vulvar squamous carcinogenesis in this population. One case was associated with lichen sclerosus. The patients with yolk sac tumors ranged in age from less than 1 year to 20 years (mean 12) and 67% of cases were stage I at presentation. An insufficient number of cases have been reported to define their prognosis, although some cases were notably aggressive. The few reported cases of melanoma are distinctive only because they were all associated with lichen sclerosus, suggestive of some role for the latter in their pathogenesis. The average age of patients reported with ES/PNET was 15 years (range 3.3 to 20). At least half of the reported cases were advanced stage at presentation, and patient outcomes were notably poor: 62.5% were dead of disease at follow-up. Pediatric vulvar malignancies are rare and are mostly comprised of 5 entities. Their accurate pathologic classification is necessary to facilitate optimal management.

Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review

Objective. Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. With numerous controversies as regards to the nomenclature, diagnosis and its association with neoplastic conditions, we decided to conduct a scoping review on this subject. Data Source. A review protocol was developed, and the Knowledge Resource Services website was used to do a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” “diagnosis,” “lichen sclerosus et atrophicus,” “kraurosis,” “vulvar dystrophy,” and “Lichen Sclerosus”. Study Selection. The search was limited to published data from the last ten years, i.e., from July 2009 onwards and in the English language. A total of 338 articles pertaining to VLS were obtained. Older data were accessed if particular information was sought for. Results & Conclusion. The presentation is bimodal, i.e., one in prepubertal girls (average age: 7.6 years) and the other in peri- and postmenopausal women (average age: 52.6 years). However, many cases also present during reproductive years. Studies suggest a multifactorial origin as far as etiology is concerned, including a genetic, autoimmune, hormonal, and local infectious background. It affects the genital labial, perineal, and perianal areas and manifests as a patchy, thin, glistening, ivory-white area. Diagnosis is mainly based on clinical features. Biopsy is seldom required. It has been well established as a precursor lesion of dVIN and vulvar carcinoma.

Diagnosis and Treatment of Vulvar Lichen Sclerosus: An Update for Dermatologists

Vulvar lichen sclerosus is an important skin disease that is common in women in their 50 s and beyond; however, it can also affect females of any age, including children. If not treated, it has the potential to cause significant and permanent scarring and deformity of the vulvar structure. In addition, if untreated, it is associated with a 2-6% lifetime risk of malignant squamous neoplasia of the vulva. Lichen sclerosus has been considered a difficult to manage condition; however, both serious complications can potentially be prevented with early intervention with topical corticosteroid, suggesting that the course of the disease can be treatment modified.