Vulvar and vaginal melanoma: Case series and review of current management options including neoadjuvant chemotherapy

ObjectiveWe report our experience with vulvar (Vu) and vaginal (Va) melanoma, with review of surgical and adjuvant therapy guidelines and description of our use of neoadjuvant therapy in selected cases.MethodsWe reviewed patients seen at Mayo Clinic for management of Vu or Va melanoma, January 1993-February 2012. Surgical treatment, pathologic and outcome data were abstracted. Overall survival (OS) and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method, and compared between subgroups using the log-rank test.Results50 patients underwent surgery for primary or recurrent melanoma (Vu = 36, Va = 14). The 5-year OS rate was 30.9%, with median OS of 3.3 years. Adjuvant therapy was given to 30.6% of Vu cases with varying combinations of agents. Among Vu patients, after adjusting for node status and depth of invasion, adjuvant therapy was not associated with improved OS (p = 0.39) or RFS (p = 0.31). Preoperative chemotherapy was used in 2 Va cases. Despite temozolomide followed by exenteration for a 4 cm multi-focal lesion, one patient died within 3 months. The second patient, with a 2 cm vaginal lesion, demonstrated a partial response to carboplatin and paclitaxel (CP). After local excision and lymphadenectomy she received additional CP with bevacizumab and remains disease free at 5 years. CP with bevacizumab was also used in 1 Vu case with a solitary 5 cm midline lesion. She underwent vulvectomy after a partial response, received additional CP and bevacizumab postoperatively, and remains without disease at 2 years.ConclusionPreoperative chemotherapy with CP and bevacizumab may improve treatment outcomes, particularly for Va and large Vu lesions.

► Neoadjuvant therapy for vulvar/vaginal melanoma may help reduce extent of resection. ► Preoperative therapy may identify post-operative therapy candidates. ► Response to preoperative therapy may be prognostic.