Vulvar melanoma

Vulvar melanoma accounts for about 5% of malignant neoplasms of the vulva. The involvement of the clitoris, the labia minora and labia majora is characteristic. There are pigmentary and pigmentless forms. This is an extremely aggressive tumor, prone to extensive metastasis, even with small sizes. From a prognostic point of view, the most important level of invasion according to Clark (Clark WH, 1959) and the thickness of the tumor according to Breslow (A.Breslow). There are 5 levels of growth according to Clark: 1) the epidermal level is a non-invasive tumor (melanoma in situ). There are no documented cases of metastasis of vulvar melanoma at this level; 2) invasion of melanoma cells through the basement membrane into the papillary dermis (up to 1 mm). At this level of invasion, metastases develop in 5% of cases; 3) the papillary-reticular level of invasion of the dermis is characterized by the germination of the tumor in the papillary layer (1.1-2 mm). Metastases develop at this level in 50% of cases; 4) tumor invasion into the reticular layer of the dermis (> 2 mm); 5) the tumor spreads into the subcutaneous fat. As the tumor grows and its invasion into the deeper layers of the epithelium (levels 2-5), survival rates are steadily decreasing, the relapse rate in case of damage to the subcutaneous tissue (level 5) is 78%. At the same time, metastases in regional lymph nodes were noted only in patients with 4th and 5th levels of invasion. A. Breslow suggested measuring the thickness of the tumor to hundredths of a millimeter, while the 3rd level according to Clark was heterogeneous according to the forecast, with a thickness of less than 0.76 mm it turned out to be identical to the 1st and 2nd levels, at 0.76 mm and more – closer to the 4th level of invasion. The prognosis sharply worsens when the thickness of the tumor is more than 1.5 mm. It is difficult to make a correct and timely diagnosis of vulvar melanoma arising from congenital or acquired pigmented nevi. In such cases, recognition of the phase of transition of the pigmented nevus to melanoma (the activation phase of the nevus) is of great importance. Symptoms of anxiety are: rapid growth of the nevus and an increase in its density, a change in pigmentation (often increased, sometimes a decrease), the appearance of redness in the form of an asymmetric corolla around the nevus, ulceration with the formation of a crust and slight bleeding, the appearance of papillomatous growths, cracks, the appearance of new nodules satellites), swollen lymph nodes. With vulvar melanoma, a biopsy is unacceptable, since it leads to a quick generalization of the process. Of great importance is the assessment of anamnestic data, a cytological examination of smears, fingerprints from the surface of the tumor, the definition of metastatically changed lymph nodes. Vulvar melanoma can metastasize hematogenously, bypassing the phase of regional metastases. In advanced cases, lymphogenous and hematogenous metastases are more often noted. The localization of hematogenous metastases is diverse: more often the lungs and liver are affected, less often – the brain, kidneys, adrenal glands and cosgs. Damage to any organ and tissue is possible. Choosing the best treatment for vulvar melanoma is not always easy. With a localized primary tumor, surgical treatment is the treatment of choice. It is necessary to widely (departing at least 3 cm from the most distant satellite) and deeply (within the fascial case) to excise the vulva tissue. Vulvectomy with inguinal-femoral lymphadenectomy and, if necessary, pelvic lymphadenectomy are considered the operation of choice for deep damage. In recent years, in patients with generalized forms of vulvar melanoma, new chemotherapy and immunotherapy regimens have been used, which allows achieving objective remission of the disease. The most effective for melanoma are dacarbazine (mono-efficacy 20-22%), nitrosourea derivatives (15-24% effective) and platinum (15-20%). Based on these drugs, combined chemotherapy regimens are created that are used to treat disseminated vulvar melanoma. High efficacy (15–25%) and ease of use were noted in a-interferons. When combined with DTIC, cisplatin, an increase in efficiency of up to 50% and higher is noted. Synergism was also noted with a combination of a-interferons with interleukin-2 (efficiency is 45%). The main rule to prevent the development of melanoma against the background of pigmented nevus should be considered its timely treatment. 

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