Case Conference March 22th 2017

22-Mar-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

March 22^nd, 2017

Mrs Y

Vaginal Malignant Melanoma, suspected stage IV

 

Case Description:

Patient complained of brownish vaginal bump. Previously she had been operated at PMI Hospital and PA result was malignant melanoma. She was referred to Fatmawati Hospital and finally to RSCM due to extensive spread.

 

Physical examination on March 10^th, 2017:

General status:

CM. BP: 160/90mmHg, HR: 90 bpm, RR: 20x/m, T:36.3^oC, Height 153cms, Weight 53kgs

Head: Pale conjungtiva (-/-)

Neck: supraclavicula lymph nodes (-/-)

Axilla: lymph nodes (-/-)

Thorax: symmetry shape and movement of hemithorax

Cardia: no murmur, no gallop

Abd: flat, no palpable mass

Extremity: inguinal lymph nodes (-/-)

Gyn state: 

Inspection: there were brownish (darken) multiple lesions on right vaginal mucosa size diameter 5 mm to 20 mm.

Inspeculum: the brownish (darken) multiple lesions were extended to cervix.

RVT: vaginal wall no bumps, atrophic cervix, uterus size 5x4 cm, both parametriums within normal limit, TSA normal, rectal mass (-).

 

Review of pathologic results, December 6^th, 2016

Malignant melanoma

 

MRI of lower abdomen and pelvis, October 10^th, 2016

No pathologic patterns on lower abdomen and pelvis.

 

MRI of lower abdomen and pelvis, January 10^th, 2017

Right retroperitoneal solid mass size 5.1x2.8x3.4 cm extended to right psoas musculature, but not to vertebral corpus, suspected secondary malignancy. Multiple liver cysts (on segment 6,7,8 with largest diameter of 1.8 cm on segment 8).

Problem to be discussed

 

Should we do symptom palliative care or palliative radiation to the patient of vaginal malignant melanoma, suspected stage III?

Clinical question in this case will be developed by PICO approach:

Problem	Vaginal malignant melanoma, suspected stage III
Intervention	Symptom palliative care
Comparison	Palliative radiation
Outcome	Overall survival

 

  

METHODS

Search strategy

In order to answer the question above, we conduct a searching in PubMed site by using keywords “vaginal malignant melanoma”. The search was conducted on Pubmed on March 20^th, 2017.

 

Search strategy used in Pubmed conducted on March 20^th, 2017

Engine	Search Terms	Results
Pubmed	vaginal malignant melanoma	195

    

 

 

 

 

 

Vaginal malignant melanoma

 

Screening files

 

Reading full text

 

1 useful articles

 

169

 

Filtering titles

 

Pubmed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1. Flowchart of search strategy

 

Selection

From the articles, limitation was given for publication more than 10 years, no abstract, not available in full text, not written in English, or articles which had no related titles. After the process, there was two articles which were representable.

 

Critical Appraisal

A large retrospective multicenter study of vaginal melanomas: implications for new management Vayssea C. et. al. Melanoma Research 2013, 23:138–146

A.      Are The Study Results Valid?

1.       Was there a representative and well-defined sample of patients at a similar point in the course of disease?	Yes
2.       Was follow-up sufficiently long and complete?	Yes
3.       Were objective and unbiased outcome criteria used?	Yes
4.       Was there adjustment for important prognostic factors?	Yes

 

 

B.      What Were the Results?

1.       How large is the likelihood of the outcome events in a specific period of time?	NA
2.       How precise are the estimates of likelihood? (Consider 95% CI)?	NA

C.      Can The Results be applied to your patients?

1.       Were the study patients similar to my own?	Yes
2.       Are the results useful for reassuring or counseling patients?	Yes

D.      CONCLUSIONS

1.       The results or recommendations are valid?	Yes
2.       The results clinically important?	Yes
3.       The results are relevant to my practice?	Yes

 

Vulvar/vaginal melanoma: an updated surveillance epidemiology and end results database review, comparison with cutaneous melanoma and significance of racial disparities.

Mert I  et. al. Int J Gynecol Cancer. 2013 Jul;23(6):1118-25.

A.      Are The Study Results Valid?

1.       Was there a representative and well-defined sample of patients at a similar point in the course of disease?	Yes
2.       Was follow-up sufficiently long and complete?	Yes
3.       Were objective and unbiased outcome criteria used?	Yes
4.       Was there adjustment for important prognostic factors?	Yes

B.      What Were the Results?

1.       How large is the likelihood of the outcome events in a specific period of time?	NA
2.       How precise are the estimates of likelihood? (Consider 95% CI)?	NA

C.      Can The Results be applied to your patients?

1.          Were the study patients similar to my own?	Yes
2.          Are the results useful for reassuring or counseling patients?	Yes

D.      CONCLUSIONS

1.       The results or recommendations are valid?	Yes
2.       The results clinically important?	Yes
3.       The results are relevant to my practice?	Yes

 

 

Discussion

Melanomas is actually one of skin cancer types which can also the mucosal epithelium for example epithelium layers that lining the respiratory, alimentary, and genitourinary tracts. This type of melanoma is known as mucosal melanoma. Mucosal melanomas generally carry a worse prognosis than those arising from cutaneous sites. It is rare, therefore our understanding of these malignancies and their optimal management remains limited. An estimated 20 percent of mucosal melanomas are multifocal, compared with less than 5 percent of those arising in the skin. Approximately 40 percent of mucosal melanomas are amelanotic, compared with less than 10 percent of cutaneous melanomas.

Staging of mucosal melanomas varies depending upon the primary site. However, a simplified staging system, which was originally developed for melanomas of the head and neck, can be applied to all cases of mucosal melanoma. This staging system classifies tumors into three stages:

Stage I – clinically localized disease

Stage II – regional nodal involvement

Stage III – distant metastatic involvement

Regardless of the primary site, wide local excision of mucosal melanoma offers the best chance for prolonged disease-free survival when technically feasible. Standard management of women with vaginal melanoma involves wide local excision if possible. Achieving negative margins in these cases can be difficult without pelvic exenteration given the high frequency of multifocality and anatomic constraints. However, the impact of such radical surgery upon survival when compared with more conservative procedures (with or without radiotherapy) is unclear. Most patients will ultimately develop distant metastatic disease regardless of the completeness of surgical resection. The significant disease complications that result from primary site failure must be balanced against the morbidity of a more aggressive resection. Thus patient preferences, as well as quality of life considerations, are critical in determining the extent of surgery.

In a large cohort of malignant melanoma study (Vayssea C. et. al. 2013), The median survival of black patients was 16 months in the vulvar/vaginal melanoma group and in the nonblack population was 39 months. Both numbers were significantly poorer compare to the cutaneous group (versus 124 months and 39 months, respectively). The SEER data demonstrate that radiation therapy is an independent negative prognostic factor for survival in cutaneous melanoma but not in vulvar/vaginal melanoma. Patients who received radiation therapy likely had more aggressive disease, and this was used in an adjuvant setting. Additionally, whereas radiation may have offered better locoregional control, these patients had no OS benefit as their tumors likely recurred elsewhere.

Other cohort study in French (Mert I  et. al. 2013), patients presenting with vaginal melanoma has been assessed in a large multicentric retrospective study. The databases of 12 French institutions were searched for primary vaginal melanomas managed between 1990 and 2007. The median age of the patients was 63.5 years (42–88 years). Twenty-eight patients were classified as International Federation of Gynecology and Obstetrics (FIGO) stage I, five as stage II, six as stage III, and one as stage IVA. Forty-two patients underwent surgical resection of the tumor, nine patients received local adjuvant treatment, and 10 received systemic adjuvant therapy. The median relapse-free survival was 10.9 months. The rate of metastasis was increased for advanced FIGO stages (P < 0.01). The median overall survival (OS) was 28.4 months. The finding of lymph node metastasis adversely affected OS (P < 0.01). Conservative surgery and radiotherapy were associated with a decrease in metastasis-free and OS (P < 0.01) compared with surgery alone, this group of patients presenting with advanced FIGO stages (P = 0.02).

 

Conclusion

Based on the current data, patient should be continued with symptom palliative care only. Distant metastasis was associated with poor prognosis.  

 

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