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First Author: Ryan Loreno Lym, Case Western Reserve University
School of Medicine, Class of 2016
Introduction: Primary vaginal melanoma is a rare and aggressive
cancer. It accounts for less than 3% of vaginal cancers and less
than 1% of malignant melanomas with an incidence of 0.26/10,000
women per year. Five-year survival rate ranges from 10-20% and
there is no effective treatment. UV radiation is not the causative
factor and its etiology is unknown. Workup requires pelvic
examination of a vaginal lesion with biopsy and histopathological
Case: A 79-year-old woman with a history of endometrial
carcinoma status post total hysterectomy in January 2013 was found
to have a vaginal lesion in January 2014 on a routine pelvic exam.
The exam was done according to current PAP smear guidelines for a
patient whose hysterectomy was performed for endometrial carcinoma.
The lesion was biopsied and determined to be primary vaginal
melanoma. It was excised and initial staging showed no evidence of
A follow up pelvic exam in March showed recurrence of three
separate vaginal lesions that demonstrated recurrent melanoma. They
were excised and PET-CT showed no distant metastasis. She
subsequently completed whole pelvic radiation but in July a staging
CT scan showed a lesion in the left lung that was confirmed to be
metastatic melanoma. The patient was then put on Ipilimumab
In September she was admitted for complaints of dyspepsia,
diarrhea, headache, and dyspnea concerning for progression of
metastatic disease and Ipilimumab toxicity. EGD demonstrated
erosive gastritis secondary to NSAID use. Bowels were positive for
Clostridium Difficile and she was treated with metronidazole. CT
scan showed diffuse metastases to the lung, liver, and pancreas.
Brain metastasis was confirmed with volumetric MRI. Thoracentesis
with subsequent PleurX placement was performed in an effort to
relieve the dyspnea felt secondary to the diffuse lung metastases
and malignant pleural effusion. Upon discharge it was established
that she had failed Ipilimumab therapy and possible options for
future management included gamma knife radiation with
considerations for hospice and palliative care.
Discussion: Current guidelines recommend against pelvic exams in
low risk women such as those older than 65 with adequate screening
history or in those who have had a total hysterectomy for benign
reasons. However, this case illustrates the importance of follow up
pelvic exams in high-risk individuals. For this patient, despite
her age and total hysterectomy, her history of endometrial
carcinoma and primary vaginal melanoma prompted the need for
post-treatment surveillance by pelvic exam. Her exams were
important in detecting the presence of her primary vaginal melanoma
and its recurrence.
September 2015 Issue of IMpact