Insights in Gynecologic Oncology
Open Access

Melanoma is a type of skin cancer that arises from melanocytes, the cells responsible for producing melanin. While most people associate melanoma with skin lesions, it can also occur in mucosal surfaces, including those of the gynecologic tract. Gynecologic tract melanoma, although rare, poses significant challenges in diagnosis, treatment, and management. This article provides a comprehensive review of clinical approaches to understanding, diagnosing, and treating gynecologic tract melanoma [1].

Understanding gynecologic tract melanoma

Epidemiology and risk factors

Gynecologic tract melanoma is an uncommon form of melanoma, representing a small fraction of all melanoma cases. It can arise in various sites, including the vulva, vagina, cervix, and ovaries.

Several risk factors are associated with melanoma development in general, and while specific data on gynecologic tract melanoma is limited, some common risk factors include:

• History of skin melanoma: Women with a history of cutaneous melanoma have an increased risk of developing melanoma in other areas.
• Genetic factors: Mutations in genes such as BRAF and NRAS can predispose individuals to melanoma. Family history of melanoma also increases risk.
• Environmental factors: Ultraviolet (UV) exposure is a known risk factor for skin melanoma; however, its role in mucosal melanoma is less clear. Other environmental and lifestyle factors may also contribute.
• Immunosuppression: Individuals with weakened immune systems, whether due to medical conditions or treatments (such as organ transplants), are at higher risk for melanoma [2].

Clinical presentation

Gynecologic tract melanoma can present with various symptoms depending on its location:

• Vulvar melanoma: This is the most common form of gynecologic tract melanoma. Symptoms may include a pigmented lesion, itchiness, pain, or bleeding.
• Vaginal melanoma: Often asymptomatic, it may be detected during a gynecological examination or when it presents with abnormal vaginal bleeding or discharge.
• Cervical melanoma: This rare presentation may also be asymptomatic or could present with irregular bleeding, pain, or other signs of cervical disease.
• Ovarian melanoma: While primary ovarian melanoma is rare, secondary involvement from metastatic spread can occur, leading to abdominal pain, bloating, and other gastrointestinal symptoms.

Diagnosis

Diagnosing gynecologic tract melanoma requires a high index of suspicion and a multidisciplinary approach. Key steps in diagnosis include:

• Clinical examination: A thorough pelvic examination is essential, especially for women presenting with symptoms related to the gynecologic tract [3-6].
• Histopathological evaluation: A biopsy of the suspicious lesion is crucial for confirming the diagnosis. Histopathology will reveal atypical melanocytes and help classify the melanoma based on the thickness (Breslow depth) and presence of ulceration.
• Imaging studies: Imaging modalities such as ultrasound, MRI, or CT scans may be employed to assess for metastasis or lymph node involvement.
• Sentinel lymph node biopsy: This procedure may be performed to evaluate potential spread to lymph nodes and help stage the disease.

Staging

Staging is critical for determining prognosis and treatment strategies. The American Joint Committee on Cancer (AJCC) staging system for melanoma considers tumor thickness, ulceration, lymph node involvement, and distant metastasis. Staging determines the appropriate clinical approach and guides treatment decisions.

Treatment approaches

Surgical management

Surgery is the primary treatment for localized gynecologic tract melanoma:

• Wide local excision: The tumor and a margin of healthy tissue are removed to minimize the risk of recurrence. The width of the margin depends on the tumor thickness and location.
• Lymphadenectomy: If sentinel lymph node biopsy indicates involvement, a complete lymphadenectomy may be performed to remove affected lymph nodes and reduce the risk of metastasis [7].

Systemic Therapies

For advanced or metastatic gynecologic tract melanoma, systemic therapies become essential:

1. Immunotherapy:

• Checkpoint inhibitors: Drugs such as pembrolizumab and nivolumab target the PD-1 pathway, enhancing the body’s immune response against melanoma cells.
• CTLA-4 Inhibitors: Agents like ipilimumab may also be used, often in combination with PD-1 inhibitors for improved efficacy.

2. Targeted Therapy:

BRAF/MEK Inhibitors: For patients with BRAF mutations, targeted therapies such as vemurafenib and cobimetinib can be effective. These treatments aim to inhibit cancer cell growth by targeting specific pathways involved in melanoma progression.

3. Chemotherapy: Traditional chemotherapy is less effective for melanoma but may be considered in some cases where other options are not viable.

Radiation Therapy

Radiation therapy may be employed in specific scenarios, such as:

• Palliative care: To relieve symptoms from metastatic disease.
• Adjuvant therapy: After surgical resection in certain high-risk patients to reduce recurrence.

Prognosis and follow-up care

The prognosis for gynecologic tract melanoma varies based on several factors, including tumor thickness, ulceration, and the presence of metastasis. Early-stage melanomas have a better prognosis, while advanced disease presents significant challenges.

Regular follow-up is essential for monitoring recurrence and managing potential long-term effects of treatment. Survivorship care plans should include:

• Physical examinations: Periodic checks for recurrence or new lesions.
• Imaging Studies: As indicated, based on individual risk factors.
• Psychosocial Support: Addressing the emotional impact of a melanoma diagnosis and ensuring access to mental health resources.

Conclusion

Gynecologic tract melanoma is a rare but significant condition requiring comprehensive and multidisciplinary clinical approaches. Understanding the unique aspects of diagnosis and treatment is crucial for improving outcomes for affected women [8]. Ongoing research into targeted therapies and immunotherapies offers hope for enhanced survival rates and better quality of life for patients diagnosed with this challenging disease. Through early detection, prompt treatment, and vigilant follow-up, the management of gynecologic tract melanoma can be optimized, ultimately leading to improved patient outcomes.

References

1. Leduc D, Biringer A, Lee L, Dy J, Azzam H, et al. (2015) Induction of labour. J Obstet Gynaecol Can 37: 380.

Google Scholar

2. Rade B, Mitku Y, Weldemicheal A, Zenebe Z, Desalegn A (2018)Induction of Labor and its Determinant Factors: Retrospective Cross-Sectional Study from a Public Hospital in Ethiopia. J Preg Child Health 5: 2.

Indexed at, Google Scholar, Crossref

3. Mozurkewich EL, Chilimigras JL, Berman DR, Perni UC, Romero VC, et al. (2011)Methods of induction of labour: a systematic review.BMC Pregnancy and Childbirth 11: 84.

Indexed at Google Scholar, Crossref

4. Girma W, Tseadu F, Wolde M (2016)Outcome of induction and associated factors among term and post-term mothers managed at Jimma University specialized hospital: a two years retrospective analysis.Ethiop J Health Sci 26: 123-132.

Indexed at Google Scholar, Crossref

5. Tolcher MC, Hokenstad AN, Weaver AL, McGree ME, Rose CH, et al. (2019)Clinical Impact of a Restrictive Labor Induction Approval Process. Gynecol Obstet Invest 84: 166-73.

Google Scholar Crossref

6. Berhan Y, Dwivedi A (2007)Currently used oxytocin regimen outcome measures at term & postterm. I: Outcome indicators in relation to parity & indication for induction. Ethiop Med J 45: 235.

Indexed at, Google Scholar

7. Curtin SC, Osterman MJ, Uddin SF, Sutton SR, Reed PR (2013)Source of payment for the delivery: births in a 33-state and District of Columbia reporting area, 2010. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Centre for Health Statistics, National Vital Statistics System 62: 1-20.

Indexed at, Google Scholar

8. Zeitlin J, Mohangoo A, Delnord M, Cuttini M (2013)Committee E-PS, The second European Perinatal Health Report: documenting changes over 6 years in the health of mothers and babies in Europe.J Epidemiol Community Health 67: 983-985.

Indexed at, Google Scholar, Crossref