Vulva
Malignant neoplasms
Melanoma

Author: Priya Nagarajan, M.D., Ph.D. (see Authors page)

Revised: 9 October 2017, last major update February 2015

Copyright: (c) 2002-2017, PathologyOutlines.com, Inc.

PubMed Search: Melanoma vulva "loattrfree full text"[sb]

Cite this page: Nagarajan, P. Melanoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/vulvamelanoma.html. Accessed October 23rd, 2017.
Definition / general
  • Melanoma constitutes about 4 - 10% of all vulvar malignancies (Int J Gynecol Cancer 2013;23:1118)
  • Second most common malignant neoplasm after squamous cell carcinoma
Epidemiology
Sites
Clinical features
  • May be discovered during routine gynecologic examinations
  • Usually present as pigmented and sometimes nonpigmented lesions (macules, patches, nodules)
  • May be ulcerated
  • May present with multiple lesions (satellitosis)
Diagnosis
  • Histologic examination is essential
Laboratory
  • Serum lactate dehydrogenase levels > 200 to 225 U/L are associated with poor survival
Radiology description
Radiology images

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CT scan, enlarged lymph node

Prognostic factors
  • Age: patients that are 68 years or younger at diagnosis have a better prognosis
  • Histologic parameters:
  • Stage:
    • Patients with localized disease (stage 0, I, II) have a better prognosis (Obstet Gynecol 2007;110:296)
    • Higher number of positive lymph nodes is associated with worse prognosis
  • Strong and diffuse c-kit expression may be associated with a worse prognosis (Int J Mol Med 2014;33:784)
Case reports
Treatment
  • Surgical resection with adequate margins is the principal management
  • Radiation
  • Chemotherapy
  • Topical imiquimod therapy
Clinical images

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Nodule and ulcer

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Large friable, gray white growth

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Vulvar melanoma

Gross description
  • Preservation of specimen orientation is critical for thorough evaluation of peripheral and deep tissue margins
Microscopic (histologic) description
  • Vulvar melanomas are evaluated and staged similar to cutaneous melanomas
  • Most of the melanomas involving the cutaneous surface only are traditionally classified based on the histologic type (superficial spreading being the most common type at this site)
  • However, when mucosal surfaces are involved, classifying them as mucosal lentiginous type would be most appropriate
  • See CAP: Cancer Protocol Templates [Accessed 9 October 2017]
  • Following histologic parameters should be included in the report:
    • Histologic type
    • Clark (anatomic) level
    • Breslow thickness (primary tumor thickness, if completely mucosal)
    • Presence of radial or nontumorigenic growth phase
    • Presence of vertical or tumorigenic growth phase
    • Mitotic rate per millimeter squared
    • Presence of ulceration (the microscopic size of ulceration is often included)
      • Must exercise caution in resection specimens as the ulceration might represent prior biopsy site
    • Presence of regression (mention percentage of regression, is associated with a poor prognosis if > 75%)
    • Presence of lymphovascular space invasion (the use of MART1 / MelanA plus D2-40 or CD34 immunostains is more sensitive)
    • Presence of perineural invasion (size of nerves involved should be mentioned)
    • Presence of microscopic satellitosis
    • Presence of tumor infiltrating lymphocytes (presence or absence; brisk vs. nonbrisk)
    • Presence of associated melanocytic nevi
    • Predominant cytology of the tumor cells
    • Status of surgical margins (for in situ and invasive melanoma)
  • Sentinel lymph nodes:
    • Examination of several H&E sections cut at various depth into the paraffin block and the use of immunohistochemistry for melanocytic markers are routinely employed to detect single cell metastases
Microscopic (histologic) images

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Pleomorphic spindled to epitheloid cells

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Cells in sheets

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HMB45+



Images contributed by Dr. Priya Nagarajan:
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Melanoma in situ

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Melanoma in situ vs. atypical melanocytic hyperplasia

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Mostly in situ, minimal invasive component

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Invasive and in situ melanoma


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Polypoid melanoma: low to intermediate magnification

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High magnification

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Melanoma with ulceration


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Heavily pigmented

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Recurrence in subcutaneous fibroadipose tissue

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Isolated nodal metastases


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MelanA (three images)

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SOX10

Positive stains
Negative stains
Molecular / cytogenetics description
Differential diagnosis