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

Objective: We 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.

Methods: We 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.

Results: 50 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.

Conclusion: Preoperative chemotherapy with CP and bevacizumab may improve treatment outcomes, particularly for Va and large Vu lesions.