Vulvo-vaginal melanoma--should radical surgery be abandoned?

Clinical outcome of 31 patients with primary malignant melanoma of the vagina

Objective

To investigate the clinical characteristics of and prognostic factors for primary malignant melanoma of the vagina.

Methods

Clinical data from 31 patients treated for primary malignant melanoma of the vagina at the Sun Yat-sen University Cancer Center between March 1970 and June 2005 were retrospectively analyzed.

Results

The median age was 58 years (range, 18 to 73 years), and the main symptoms reported were vaginal bleeding and vaginal discharge. Most tumors were of the nodular type and classified as stage I according to International Federation of Gynecology and Obstetrics staging criteria. Surgery was performed on 22 patients, chemotherapy was administered to 7 patients, and immunotherapy was administered to 19 patients. Recurrent tumors developed in 11 patients (35.5%) during a median follow-up period of 20.2 months (range, 1 month to 18 years). The 5-year overall survival rate was 32.3%. Univariate analysis revealed that macroscopic tumor growth and the treatment method significantly affected survival outcome (p=0.039 and p<0.001, respectively), whereas the radicality of surgery did not (p=0.296). Multivariate analysis revealed that macroscopic tumor growth (hazard ratio [HR], 4.1; 95% confidence interval [CI], 1.4 to 12.1; p=0.010) and treatment method (HR, 0.3; 95% CI, 0.1 to 0.9; p=0.025) were independent prognostic factors for overall survival.

Conclusion

Patients with primary vaginal melanoma have a poor prognosis. Macroscopic tumor growth and treatment method are prognostic factors for primary malignant melanoma of the vagina.

Mucosal melanomas: a case-based review of the literature

Mucosal melanoma is a rare cancer that is clearly distinct from its cutaneous counterpart in biology, clinical course, and prognosis. Recent studies have shown important differences in the frequencies of various genetic alterations in different subtypes of melanoma. Activating mutations in the c-KIT gene are detected in a significant number of patients with mucosal melanoma. This observation has resulted in the initiation of several clinical trials aimed at exploring the role of receptor tyrosine kinases that inhibit c-KIT in this patient population. We herein present a comprehensive literature review of mucosal melanoma along with case vignettes of a number of pertinent cases. We further discuss melanomas of the head and neck, the female genital tract, and the anorectum, which are the three most common sites of mucosal melanoma, with a particular focus on the diagnostic, prognostic, and therapeutic data available in the literature.

Vulvar melanoma: report on eleven cases and review of the literature

CONTEXT AND OBJECTIVE

Vulvar melanoma is a rare disease. We describe the experience of a single institution and review the literature.

DESIGN AND SETTING

Retrospective study at the Department of Gynecology, Hospital do Cancer A. C. Camargo.

METHODS

Eleven patients with vulvar melanoma attended between January 1987 and December 2006 were reviewed regarding clinicopathological characteristics, surgical therapy and follow-up.

RESULTS

The initial symptoms were vulvar lesions, pruritus, pain and bleeding. The median age was 64.8 years. The median depth of invasion was 3.08 mm. The staging ranged from IB to IIIC (American Joint Committee on Cancer, 2002). All the patients underwent vulvectomy. Two patients did not undergo primary elective lymphadenectomy. Bilateral inguinal lymphadenectomy was performed on five patients, and one had unilateral inguinal lymphadenectomy. Sentinel lymph node investigation was performed on three patients. Five patients had locoregional recurrence. Prolonged survival was only achieved in the absence of lymph node involvement. The median follow-up was 56 months. The median disease-free survival was 15 months and the median overall survival was 29 months.

CONCLUSIONS

The prognosis for patients with vulvar melanoma is generally poor, with a high tendency towards regional and distant recurrence. Depth of invasion and lymph node involvement are the most important prognostic factors. In most cases, resection of the lesion with adequate margins may replace vulvectomy. Elective inguinal femoral lymphadenectomy remains the standard lymph node staging procedure. Sentinel lymph node investigation is feasible and should be performed by a multidisciplinary team with experience of this method.

Vaginal melanoma: a current review

Vaginal melanoma is rare, accounting for less than 3% of primary vaginal tumours. It principally affects postmenopausal women, however no risk factors have been identified. Patients frequently present with vaginal bleeding, but the tumour is locally advanced at presentation. Surgery is only the potential cure. The relative merits of radical surgery-vaginectomy and iliac or inguinal lymphadenectomy-versus wide local excision with prompt treatment of recurrences remains uncertain. High dose external radiotherapy and regional chemotherapy trials have been encouraging, although there is no definite survival advantage. Patients should be offered excisional therapy with the opportunity to participate in trials of adjuvant therapy. Prognosis is poor with a five-year survival of 5-21%. Effective screening measures are required enabling earlier diagnosis.

Management of melanomas of the female genital tract

PURPOSE OF REVIEW

The significant increase in cutaneous melanomas over the past 30 years has led to studies resulting in advances in their diagnosis, staging, surgical treatment, and adjuvant therapies. Similar approaches have been investigated in patients with far rarer malignant melanomas of the female genital tract. This review will summarize the current state of knowledge on the incidence, causes, presenting symptoms, prognostic factors, therapeutic approaches, and outcomes, site-by-site, for primary melanomas of the vulva, vagina, urethra, ovary, and the uterine cervix.

RECENT FINDINGS

Surgery remains the initial treatment of choice for localized melanomas of the female genital tract, with less radical, organ function preserving resections demonstrating similar control rates compared with more radical surgical approaches in vulva and possibly vaginal melanomas. Radiation therapy may play a role in the treatment of patients with close resection margins, regional nodal metastasis, or unresectable tumors. Sentinel lymph node studies, positron emission tomography and computed tomography scans for staging and evaluation of response, and adjuvant chemo or biochemotherapy warrant further investigation.

SUMMARY

The results of treatment for female genital tract melanomas remain poor. Although surgery remains the initial treatment of choice for localized disease, adjuvant local-regional, and systemic therapies are needed.

Vulvar Melanoma

OBJECTIVES

To determine the prognostic factors associated with the survival of vulvar melanoma patients.

METHODS

Data were obtained from the Surveillance Epidemiology and End Results database from 1973 to 2003. Kaplan-Meier survival curves and Cox regression models were used for analysis.

RESULTS

Of the 644 vulvar melanoma patients, the median age was 68 years. Of these 572 women were white, 28 were Hispanic, 18 were African-American, and 14 were Asian. A total of 302 had localized disease, 168 had regional disease, and 28 had distant disease. Of the participants who underwent surgical resection, 171 (26.6%) had conservative surgery, 164 (25.5%) had radical excision, and 241 (37.5%) had unspecified surgical resections. One hundred seventy-nine (27.8%) had lymph node resections, and 33 patients had concurrent radiation therapy. Nodal metastases were identified in 58 (9%) of the participants. The 5-year disease-specific survival rates for those with localized, regional, and distant disease were 75.5%, 38.7%, and 22.1%, respectively (P<.001). Women aged 68 years or younger had a better survival rate than older patients (72.0% compared with 47.7%; P<.001). Those with 0, 1, and 2 or more positive lymph nodes had survival rates of 68.3%, 29%, and 19.5%, respectively (P<.001). In a multivariable analysis, younger age, localized disease, and negative lymph nodes were independent prognostic factors for improved survival.

CONCLUSION

Age, stage, and lymph node involvement were significant factors for survival in vulvar melanoma.

LEVEL OF EVIDENCE

III.

Vulvar melanoma: a report of 20 cases and review of the literature

BACKGROUND

Vulvar melanoma is the second most common vulvar malignancy and represents a significant women's health issue.

OBJECTIVE

To report experience with 21 cases of vulvar melanoma in 20 patients and to review the literature about the condition.

METHODS

Parameters retrospectively reviewed included age at diagnosis, family history of melanoma, location on the vulva, atypical nevi, Breslow depth, ulceration status, histologic pattern, presenting signs and symptoms, and the results of sentinel lymph node biopsy. Molecular characterization of the melanocortin type 1 receptor was performed in 1 patient.

RESULTS

A family history of cutaneous melanoma was present in 15% of cases. The mean Breslow depth was 2.8 mm (range, 0.0-11.0 mm). Ten patients successfully underwent sentinel lymph node biopsy, results of which were positive in 2 (20%). Reported for the first time is that one patient had a germline mutation in the melanocortin type 1 receptor.

CONCLUSION

Vulvar and cutaneous melanoma behave similarly despite their unique pathogeneses. Sentinel lymph node biopsy can be performed successfully for vulvar melanoma.

Vulvar Melanoma: Review of Diagnosis, Staging, and Therapy

OBJECTIVES

To update, assimilate, and bridge the contemporary literature on vulvar and cutaneous melanoma regarding diagnosis, staging, and therapy to provide a useful clinical reference for managing and counseling for affected patients.

MATERIALS AND METHODS

A computerized search for reports in the literature up to June 2003 was carried out using PubMed and MEDLINE databases. Multidisciplinary involvement was used in evaluating the available data and formulating conclusions.

RESULTS

More than 300 reports were reviewed. Diagnosis, staging, and therapy aspects of vulvar melanoma are summarized.

CONCLUSIONS

Vulvar melanoma represents a subtype of cutaneous melanoma, with similar prognostic and staging factors. The most recent American Joint Committee on Cancer staging system for cutaneous melanoma is applicable to vulvar melanoma. Sentinel lymph node biopsy is reliable for staging the regional lymph node basin for vulvar melanoma. Standardized documentation of clinical and histopathologic parameters is needed to standardize grouping of cases for future comparison studies.

Bartholin's gland carcinoma, malignant melanoma and other rare tumours of the vulva

Non-squamous cancers of the vulva encompass an exciting and broad group of tumours, including Bartholin's gland carcinoma, malignant melanoma, Paget's disease, sarcomas and lymphoma. These tumours range from innocuous lesions treatable with simple local excision, such as basal-cell carcinoma, to cancers with very poor prognosis, such as Merkel-cell tumours. All of these tumours are thoroughly reviewed, with emphasis on presenting symptoms, pathological diagnosis and optimal management approaches. The literature supporting these recommendations is reviewed. Of the utmost importance in the management of these tumours is a thorough review of the pathological diagnosis by a specialist pathologist and a gynaecological oncologist. Establishing the correct diagnosis is essential to reaching appropriate treatment decisions. Frequently this will necessitate a second opinion by a referral centre.

Radiation therapy for malignant melanoma

Although surgery remains the primary treatment for patients with localized melanoma, available data indicate that there is a need for improved local-regional control in situations where complete surgical resection may be difficult or when high-risk features are noted pathologically. Retrospective and phase II prospective studies have revealed that elective/adjuvant radiotherapy can significantly improve the local-regional control rate in these clinical settings. The impact of elective/adjuvant radiotherapy on the incidence of distant metastasis and overall survival has yet to be determined, however. Additionally, there remains a role for radiotherapy as a primary treatment alternative for elderly patients with large facial lentigo maligna melanoma. The optimal radiation fractionation schedule remains controversial. The hypofractionated regimen is well tolerated, has resulted in improved local-regional control as compared with historical surgical results, and is convenient for a group of patients in whom survival expectations are low. Significant improvements in outcome will require commensurate improvements in systemic disease control. The importance of local control to reduce local morbidity, however, should not be underestimated, and future research goals should include randomized clinical trials to further define the role of adjuvant irradiation alone or in combination with systemic therapy.

Vulvar melanoma: a retrospective analysis and literature review

OBJECTIVE

This review focuses on current directions in the staging and treatment of melanoma of the vulva.

METHODS

All women treated for invasive melanoma of the vulva at the University of Virginia Health Sciences Center from 1980 through 2000 were identified through a retrospective review of the records of the Division of Gynecologic Oncology. Their treatments and outcomes were then analyzed and presented.

RESULTS

Over the 20-year study period, 14 cases of melanoma of the vulva were identified. Of the 14 patients treated with curative intent, 6 developed recurrences following the completion of primary therapy, and all are dead from their disease. The mean duration from completion of therapy to recurrence was 7.5 months; the mean survival following recurrence was 17 months.

CONCLUSION

One-centimeter skin margins appear adequate for vulvar melanomas <1 mm thick, and 2-cm margins appear adequate for intermediate-thickness melanomas (1-4 mm). In all cases it is necessary to include at least a 1-cm-deep margin extending through the subcutaneous fat to the muscular fascia below. Elective node dissection seems to offer no additional advantage in superficial lesions <0.76 mm thick, and its role in deeper lesions is still uncertain.

Vulvar melanoma at the M. D. Anderson Cancer Center: 25 years later

The purpose of this study was to review the clinical course of patients diagnosed with vulvar melanoma. Charts of patients diagnosed between 1970 and 1997 were reviewed for demographics, lesion characteristics, disease duration and extent, and treatments. Actuarial survival curves were computed by the Kaplan Meier method and compared by Cox proportional hazards regressions. Fifty-one patients (median age 54) with vulvar melanoma presented with a vulvar mass (39%), pain (30%), bleeding (24%), and itching (20%). Anatomical distribution was mucosa of the vulva (65%), vulvar epidermal site (21%), or unspecified vulva (14%), with 20% having multifocal disease at diagnosis. Histologic types were superficial spreading or nodular (50% each). Median lesion characteristics were diameter 2 cm, Breslow index 4.4 mm, and Clark level IV. Distribution of patients per American Joint Committee on Cancer (AJCC) stage was 29%, 50%, 16%, and 7% for stages I, II, III and IV, respectively. Inguinal node metastases were unilateral in 16% and bilateral in 7%. Despite complete surgical resection, 32 patients (63%) recurred. Median survival for all patients was 41 months (range, 5-324), with 91% 5-year survival for patients with stage I and 31% for stage >or= IIA (P = 0.0002). As with cutaneous melanoma, the AJCC classification, Breslow's thickness, and Clark's levels are the major predictors of overall survival (P = 0.0001 each) and disease-free survival (P <or= 0.0001, 0.0004, and 0.0002, respectively). Surgical techniques do not seem to alter the prognosis. Because vulvar melanoma carries a poor prognosis at early stages, the use of adjuvant therapies needs to be studied prospectively in women affected with this disease.

Primary malignant melanoma of the vagina: long-term remission following radiation therapy

OBJECTIVE

To describe the characteristics and clinical course of patients with primary vaginal melanoma treated at three large Austrian institutions.

METHODS

The medical records of 14 patients treated at the Departments of Obstetrics and Gynecology of the Universities of Graz and Vienna and the Salzburg Women's Hospital between 1982 and 1996 were reviewed.

RESULTS

The median age at diagnosis was 73 years. Presenting symptoms included vaginal bleeding in all patients. Three of seven patients (43%) with tumors < or = 3 cm survived longer than 5 years compared to none of seven patients with a tumor size > 3 cm. Three of nine patients (33%) who received radiotherapy either in addition to surgical excision or as primary treatment, survived for 5 years. Other potential prognostic factors such as age, location, FIGO stage, depth of invasion, Chung level, histology, cell type, mitotic count, vessel involvement, ulceration, p53 accumulation, type of surgery, type of radiotherapy, or chemotherapy did not seem to correlate with the patients' outcome. The median overall survival was 10 months (range 1-153). The 5-year disease-free and overall survival rates were 14 and 21%, respectively. All three long-term survivors recurred locally.

CONCLUSION

All three patients who had long-term survival had lesions < or = 3 cm and received either primary radiotherapy (n = 2) or adjuvant radiotherapy after complete excision of the primary lesion (n = 1). In view of the poor overall survival rates, regardless of treatment, radiotherapy may be a limited valuable alternative or adjunct to surgery in patients with primary malignant melanoma of the vagina < or = 3 cm in diameter.

Amelanotic malignant melanoma of the vulva. Case report and review of the literature

We report on a 60 year old patient with a 6 month history of vulval pruritus and an erosive vulval lesion which was mistaken for lichen sclerosus et atrophicus. Histologically the diagnosis of an amelanotic malignant melanoma of the vulva was established. We review the literature about this rare malignant tumor.

Malignant melanoma of the vulva: a review

Vulvar melanoma is an unusual tumor with a poor prognosis. Most surgeons have abandoned radical vulvectomy as the treatment of choice. The role of elective node dissection is controversial. Currently effective adjuvant therapy is lacking. In this paper 51 sources concerning melanoma and/or melanoma of the vulva were reviewed, 43 of these sources were considered to be pertinent and current enough to include in this review. The objective was to describe current knowledge about the natural history, staging, pathology, and treatment of melanoma of the vulva. It has been found that melanoma continues to be difficult to treat when in advanced stages. Microstaging systems offer clinicians the best prognostic information. In many patients, less radical surgical treatment offers equal cure rates with decreased morbidity.

Malignant melanoma of the vulva. Evaluation of prognostic factors with emphasis on DNA ploidy in 75 patients

BACKGROUND

To the authors' knowledge, the potential prognostic value of DNA ploidy in vulvar melanoma has not been evaluated in previous series.

METHODS

Clinical data and follow-up information were retrieved from the hospital records of 75 patients treated from 1956 to 1987. Histopathologic specimens were reviewed for histologic type, depth of invasion, vessel invasion, and ulceration. Flow cytometric DNA measurements were performed on paraffin embedded samples.

RESULTS

Forty-three patients had International Federation of Gynecology and Obstetrics Stage I disease, 14 Stage II, 8 Stage III and 10 Stage IV. Sixty-five patients were treated by surgery, six by radiotherapy, and four patients with advanced disease received no therapy. The surgical procedure was local excision in 17 patients, vulvectomy in 22, and radical vulvectomy with inguinal lymph node dissection in 26. Five- and 10-year corrected survival rates were 46% and 37%, respectively. Recurrences were seen in 43 (66%) of the patients treated by surgery. Independent prognostic factors for corrected survival in the entire group of 75 patients were inguinal lymph node metastases (P = 0.016), angioinvasion (P = 0.027), tumor localization to clitoris, and multifocal tumors (P = 0.043). For the 65 patients treated by surgery, independent prognostic factors for disease free survival were angioinvasion (P < 0.001), age at diagnosis (P = 0.003), DNA ploidy (P = 0.004), and ulceration (P = 0.027). The independent prognostic factors for long term survival were tumor localization to clitoris (P = 0.018), DNA ploidy (P = 0.045), and inguinal lymph node involvement (P = 0.053). Radical surgery did not improve disease free or long term survival.

CONCLUSIONS

DNA ploidy is an independent factor that predicts prognosis in patients with vulvar melanoma, and should be considered together with previously known factors. Radical surgery does not improve prognosis and is not recommended when the inguinal lymph nodes are clinically negative.

Malignant melanoma of the vulva and vagina: a report of 23 cases presenting in a 10-year period

In the 10-year period ending December 1991, 14 patients with primary melanoma of the vulva and nine with primary melanoma of the vagina were diagnosed and treated. Of the patients with vulval melanoma, three were treated surgically with wide local excision of the tumor alone, six had wide local excision with inguinal node dissection, and five had radical vulvectomy with inguinal node dissection. Four of the patients with vaginal melanoma had wide local excision; two had wide local excision with inguinal and or pelvic node dissection; and three had surgery that was more radical than this. Two years after diagnosis, all of the patients whose tumors were 2 mm thick or more had died, or were alive but had distant metastases. This was independent of the apparent surgical success of local excision of the disease. We consider that conservative procedures in the management of invasive melanoma of the lower female genital tract should be the rule, and that radical procedures should be reserved for palliation rather than cure.

Malignant melanoma of the vulva treated by radical hemivulvectomy. A prospective study of the Gynecologic Oncology Group

BACKGROUND

Beginning in 1983, the Gynecologic Oncology Group (GOG) conducted a prospective clinicopathologic study of primary malignant melanoma of the vulva. The objectives of this study were to determine the relationship of histopathologic parameters and microstaging to the International Federation of Gynaecology and Obstetrics (FIGO) staging and prognosis.

METHODS

All patients with primary untreated malignant melanoma of the vulva and no history of previous or subsequent other primary invasive malignancy were eligible for study entry. All patients were required to have modified radical hemivulvectomy as minimal therapy. Groin dissection was optional. Histopathologic specimens were reviewed for capillary space involvement, Clark's level, Breslow's depth of invasion, cell type, and melanin distribution. Patient characteristics were analyzed in their relationship to groin node status and recurrence-free interval.

RESULTS

Between 1983 and 1990, 81 patients were entered in the study. Of these, 71 were evaluable. Thirty-four patients underwent radical hemivulvectomy, and 37 patients underwent radical vulvectomy. In addition, 56 patients underwent groin node dissection. The factors that were independently correlated with groin node status were: capillary lymphatic space involvement (p = 0.0001) and central primary tumor location (i.e., bilateral/clitoral/T3) (P = 0.003). The other factors that were significant--clinical tumor size, vulvar staging (FIGO), GOG performance status, and Breslow's depth of invasion--were not independent predictors of positive nodes. The factor with the highest significant correlation with recurrence-free interval was the 1992 staging system of the American Joint Committee on Cancer (AJCC) for malignant melanoma of the skin. Using multiple regression, AJCC stage was the only independent prognostic factor. In the absence of AJCC stage, Breslow's depth of invasion was the most prognostic.

CONCLUSION

The biologic behavior of vulvar melanoma is similar to other nongenital cutaneous malignant melanoma.

Vulvar melanoma reconsidered

BACKGROUND

Melanoma of the vulva has traditionally been treated with radical vulvectomy and bilateral inguinofemoral lymphadenectomy. Cutaneous nonvulvar melanoma has been successfully treated with local excision with selective therapeutic regional node dissection.

METHODS

A retrospective analysis of 16 patients with primary malignant melanoma of the vulva who underwent surgery from 1973 to 1988 at Indiana University Hospital was conducted. The purpose of this analysis was to determine if less radical surgery, such as that performed for cutaneous nonvulvar melanoma, might be adopted for patients with vulvar melanoma without compromising 5-year survival results.

RESULTS

Surgical therapy included radical vulvectomy with bilateral inguinofemoral lymphadenectomy (n = 11), radical vulvectomy alone (n = 1), and wide local excision (n = 4). Treated International Federation of Gynecology and Obstetrics (1971) stages included I (n = 12), II (n = 3), and III (n = 1). The median age of the patients was 59 years (range, 29-79 years). The median depth of invasion according to the Breslow method was 3 mm (range, 0.1-8 mm). Patients were observed for a median of 24 months (range, 3-143 months). The Kaplan-Meier 5-year survival estimate was 30%. There were nine recurrences: five distant, one central, one nodal, and two mixed. A median depth of 0.9 mm (range, 0.1-1.75 mm) was noted in those who remained disease-free versus 4.6 mm (range, 3-8 mm) in those who experienced a recurrence (P < 0.01). None of the patients with lesion depths of 1.75 mm or smaller experienced a recurrence, whereas all of those with lesion depths larger than 1.75 mm suffered a recurrence (P = 0.0004).

CONCLUSIONS

Patients with lesion depths of 1.75 mm or smaller may be treated with wide local excision. Patients with greater lesion depths are at high risk for the development of distant metastases. The patients with well-lateralized lesions may be equally well served with a less morbid procedure deferring therapeutic node dissection until there is a regional recurrence.

Vaginal melanoma and the role of regional chemotherapy

Vaginal melanoma is a rare cancer usually diagnosed as a locally advanced disease. Aggressive surgical management of the primary tumor and local-regional recurrences, combined with the use of adjuvant radiation and chemotherapy, improves disease-free interval and, perhaps, survival times. Techniques of regional chemotherapy allow the delivery of high doses of chemotherapy to the tumor bed, while minimizing systemic toxicities. These treatments can be used to decrease tumor size, render bulky tumors resectable, and decrease the need for radical procedures. Additionally, they may help eradicate clinically inapparent local-regional disease and have a favorable effect on survival times.

Malignant melanoma of the vulva: a clinicopathologic study of 18 cases

In a study of 18 patients diagnosed with vulvar malignant melanoma between 1975 and 1991, the effect of clinical and pathologic variables on the survival was evaluated. The overall 5-year survival rate was 28.6%. In 14 cases the tumor was retrospectively microstaged with use of Breslow depth and Chung levels. International Federation of Gynecology and Obstetrics (FIGO) stage and Breslow depth did not correlate well with survival. Positivity of groin lymph nodes at initial surgery was associated with an insignificant worsening in survival. An inverse correlation, although statistically not significant, was demonstrated between advancing Chung levels and survival. It is concluded that since the data with respect to microstaging of vulvar malignant melanoma is, as yet, still limited, great caution should be used in electing less aggressive surgery than radical vulvectomy and bilateral groin lymphadenectomy for patients with early-microstage localized disease.

Management of vulvar melanoma

Considerable debate centers on the optimal treatment for vulvar melanoma, as well as those clinicopathological factors influencing prognosis. We reviewed 80 patients with vulvar melanoma seen between 1949 and 1990. Primary tumors were assessed according to Chung (47 patients) and Breslow (65 patients) microstaging systems. Fifty-nine patients (76%) underwent radical vulvectomy, ten patients (13%) had a partial vulvectomy, and nine patients (12%) had a wide local excision. Fifty-six also underwent inguinal node dissection. Median follow-up was 193 months. Median survival was 63 months. Ten-year survival by Chung level was as follows: I 100%; II, 81%; III, 87%; IV, 11%; V, 33%. Ten-year survival by tumor thickness was as follows: 0.75 mm, 48%; 0.75-1.5 mm, 68%; 1.51-3.0 mm, 44%; greater than 3.0 mm, 22%. Increased depth of invasion was associated with increased incidence of inguinal node metastasis. Cox regression analysis demonstrated prognostic significance for tumor thickness (P less than 0.001), inguinal node metastasis (P less than 0.001), and older age at diagnosis (P less than 0.001). Radical vulvectomy did not seem to improve survival over less radical procedures. Based on this experience, we recommend radical local excision for patients with malignant melanoma of the vulva. Patients who have more than a superficially invasive melanoma should also have inguinal lymph node dissection.

Rare variants of malignant melanoma

The personal experience with 5 rare types of malignant melanoma is reviewed to point out some of the practical problems in the diagnosis and management of these tumors. The rare forms discussed are conjunctival, nasal, oral, vulvar, and penile melanomas. All pigmented lesions in the oral cavity, but not the penis or vulva, should be prophylactically excised as lesions in the mouth have a higher malignant potential. Local excision of all 5 forms of primary melanomas, no matter how locally advanced they may be, is the sole treatment. Nevertheless, anatomic constraints often preclude surgery with generous margins and consequently local recurrence, particularly for conjunctival, nasal, and oral primary lesions, is usually the major first failure in treatment. Lymph node dissection is only performed if the regional nodes are palpable at the time of first presentation. Elective lymph node dissections are not performed since the patients are often elderly, the lymphatic drainage is usually ambiguous or multiple, and the disease tends to spread hematogenously rather than lymphatically. Surgery still remains the cornerstone of treatment for these rare forms of melanoma but prognosis is very poor since surgery is often a palliative rather than a curative measure. Improved survival may depend on identifying more effective chemotherapeutic and immunologic agents.

Malignant melanoma of the female genital tract. A report of nine cases in the Chinese of Hong Kong

Ten cases of malignant melanoma of the female genital tract were diagnosed in Chinese patients in Hong Kong over the 12 yr period from 1978 to 1990. Of the 9 cases considered here, 4 involved the vagina alone, 2 the vagina and cervix, 2 the uterine cervix alone, and 1 occurred on the vulva. Thus, contrary to the usual reported distribution, the vulva was an uncommon site. While the mean age of the patients was 58 yrs, 2 patients were in their thirties and both had a history of a recent pregnancy. Vaginal bleeding or discharge were the presenting symptoms in most cases. The primary origin was confirmed histologically in 6 of the 9 cases and all were of the mucosal lentiginous type. Deep invasion, beyond 3 mm, was present in all cases at the time of diagnosis. Five patients died of the disease 2-22 months after diagnosis. The 4 surviving patients were clinical Stage I and II (FIGO) when diagnosed and have a median survival of 18 months to date. Both the FIGO clinical stage and Breslow's tumor thickness proved to be good prognostic indicators.

Malignant melanoma of the vulva: clinicopathological features

From the files of the Scottish Melanoma Group, we have identified 41 cases of vulval malignant melanoma, which represents 1.7% of all the melanomas occurring in women in Scotland, during the period 1979–1989. Thirty-seven were aged 50 years or older with the mean age being 70 years. The average Breslow depth of the lesions was 6.0 mm, with 29 being greater than 3.0 mm in depth. Nineteen cases were polypoidal and 37 were ulcerated. Six patients had radical vulvectomy with lymph node dissection, three had biopsy and palliative treatment, and the majority of the remaining patients had local excision only, with surgical margins of less than 2 cm. The 5-year survival rate (available for 23 patients) is 21.7%, compared to 72% for cutaneous melanoma in females, in general, in the same population. In this series, the survival rate is poor, as the lesions occurred in elderly women and the melanomas were thick at presentation. Surgical treatment appears to have been rather conservative in those who were dead from their disease at 5 years.

Primary malignant melanoma of the vagina: a clinicopathological analysis of 10 cases

We retrospectively analyzed clinicopathological findings in 10 cases of primary malignant melanoma of the vagina. The main presenting symptoms were vaginal bleeding, vaginal discharge, and feeling of a mass. The tumors were predominantly located in the lowest one-third and in the anterolateral aspect of the vagina. Patients underwent various surgical procedures, radiation therapy, and chemotherapeutic modalities. The mean survival time and the recurrence time from the time of diagnosis were 15 and 8 months, respectively. The tumors were examined for histological characteristics of cell type, presence of melanin pigment, depth of invasion, vascular invasion, intraepithelial spread, junctional activity, and mitotic count. Of all these histological variables, the mean survival time had a significant correlation to mitotic count (P less than 0.04). We concluded that patients with lower mitotic counts (less than 6 per 10 HPF) had better survival (21 months) compared to patients with mitotic counts greater than 6 per 10 HPF who had a mean survival of only 7 months.

Malignant melanoma of the vulva: a clinicopathological study of 50 women

A clinicopathological review of 50 primary malignant melanomas of the vulva in the West Midlands region of England is presented. The overall 5-year-survival rate was 35%, when adjusted for age. Significant predictors of survival were clinical stage, patient age, tumour ulceration, cell type and mitotic rate. Tumour thickness was of prognostic importance but as a prognostic variable it did not operate independently of stage and as most lesions were deeply invasive at presentation vulval tumours must be separated for prognostic purposes into bands at greater overall thicknesses than those used for skin melanomas generally. There was no significant relation between survival and type of surgery performed as a primary therapeutic procedure.

Vulvovaginal melanoma: report of seven cases and literature review

Five cases of primary vaginal melanoma were treated at UCLA Medical Center between 1976 and 1986. Two additional cases of melanoma arising at the junction of the vulva and vagina are presented. One of seven (13%) patients is alive, with a median time to recurrence of 7 months, and median survival of 31 months. Four of five vaginal melanomas were located in the distal vagina, and all were advanced at diagnosis (greater than 3 mm depth). Mean size was 3 cm. Initial therapy was local excision in four patients and radical surgery in three. All patients had suboptimal surgical margins: two vaginal primaries had positive margins after local excision, both recurred vaginally within 5 months. Two patients had margins less than 1 mm, one died of distant metastases, the other is alive with disease 30 months after radical distal vaginectomy and hemivulvectomy with post-op pelvic radiotherapy. Three patients had melanoma in situ at the surgical margins, and each had pelvic recurrences between 6 and 26 months. Five of seven cases developed local recurrence as the initial site of treatment failure. All five vaginal cases ultimately developed distant disease, but only two patients had distant disease without local-regional recurrence. Chemotherapy and immunotherapy enabled disease stabilization in three patients. The vulvovaginal junction at the introitus is a high risk site for vaginal and vulvar melanoma. Intraoperative management requires assessment of lateral and deep spread of invasive and in situ melanoma.

Conservative therapy for melanoma of the vulva

Recent cooperative studies have demonstrated that less radical local resection of cutaneous melanomas is equally effective as a traditional radical approach. A retrospective review of vulvar melanoma was undertaken to determine if mode of therapy affected recurrence. Survival correlated independently with depth of invasion and age (p = 0.05 and p less than 0.02, respectively). In the comparison of radical vulvectomy with local excision, no patient differences in age or histopathologic variables were determined (nodal disease status, histology, mitotic count, lymphocytic infiltration, or ulceration). Radical vulvectomy did not improve survival over local therapy (p greater than 0.2). Six of eight patients whose melanoma had less than 2 mm of invasion treated with local therapy are disease free after a median of 127 months (range 6 to 300 months). For local excision, recurrences were more frequent when margins were less than 2 cm, but this was not statistically significant in this small sample. Although the current series is small and retrospective, its findings suggest that treatment recommendations of large cutaneous nonvulvar melanoma studies are applicable to vulvar melanoma. A prospective randomized study of radical versus conservative surgery for vulvar melanoma will be necessary to confirm these treatment recommendations.