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

Anorectal and Genital Mucosal Melanoma: Diagnostic Challenges, Current Knowledge and Therapeutic Opportunities of Rare Melanomas

Mucosal melanomas (MM) are rare tumors, being less than 2% of all diagnosed melanomas, comprising a variegated group of malignancies arising from melanocytes in virtually all mucosal epithelia, even if more frequently found in oral and sino-nasal cavities, ano-rectum and female genitalia (vulva and vagina). To date, there is no consensus about the optimal management strategy of MM. Furthermore, the clinical rationale of molecular tumor characterization regarding BRAF, KIT or NRAS, as well as the therapeutic value of immunotherapy, chemotherapy and targeted therapy, has not yet been deeply explored and clearly established in MM. In this overview, focused on anorectal and genital MM as models of rare melanomas deserving of a multidisciplinary approach, we highlight the need of referring these patients to centers with experts in melanoma, anorectal and uro-genital cancers treatments. Taking into account the rarity, the poor outcomes and the lack of effective treatment options for MM, tailored research needs to be promptly promoted.

Recurrent Vulvar Melanoma – a Case Report

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

Vulvar melanoma: relevant aspects in therapeutic management

Cancer of the vulva accounts for at least 1% of malignant neoplasms among women. Although rare, vulvar melanoma is the second most common histological type of vulvar cancer, representing 7-10% of all malignant vulvar neoplasms. Initial symptoms are non-specific and complete excision of the lesion is indicated in cases with suspected diagnosis. Prognosis of patients with these neoplasms is poor and remains unchanged despite the treatment approach. Hemivulvectomy with lymph node dissection is the current procedure of choice, associated or not with adjuvant therapies. We report two cases of patients presenting with late diagnosed vulvar melanoma and the relevant aspects in their therapeutic management.

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

The authors describe the sixth pediatric case to date of primary vulvar melanoma associated with lichen sclerosus and propose a practical management for such a rare cancer.

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

Objective:

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

Materials and Methods:

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

Results:

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

Conclusion:

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