Vaginal malignant melanoma: surgical challenge and need for combination treatment.

DOI: 10.4274/jtgga.galenos.2023.2023-3-11 Address for Correspondence: Ioannis D. Gkegkes e.mail: ioannisgkegkes@gmail.com ORCID: orcid.org/0000-0001-8637-5679 To the Editor, We read the article entitled “Laparoscopic radical hysterectomy and total vaginectomy for vaginal malignant melanoma with cervical metastasis” by Vardar et al. (1) with a great deal of interest. The authors present a step-bystep surgical approach for such a challenging case. Mucosal melanomas are a rare type of melanomas in comparison to cutaneous melanomas (2). For this reason, optimal management of locally advanced vaginal melanoma is poorly understood, including exenteration procedures, adjuvant radiotherapy, chemotherapy and immunotherapy with agents such as ipilimumab or nivolumab (3). A recent systematic review analyzed 15 patients with vaginal melanoma and reported that, in contrast to cutaneous melanoma, there were fewer BRAF mutations and more PI3K/AKT/mTOR pathway alterations, and so early stage and surgical extirpation affected the prognosis (4). However, a combination treatment including application of immune checkpoint inhibitors, radiotherapy and/or anti-angiogenic therapy, may have a synergistic effect in the treatment of patients with advanced vaginal melanoma (5). Moreover, a recent large cohort study from MD Anderson Cancer Center found that mitotic rate >10/mm2, nodal involvement and non-vulvar anatomic subsite were related to poor outcomes, independently of the combination of treatment (6). More specifically, the study reports 46% local control, 53% nodal control, 36% distant metastasis-free survival, 49% melanomaspecific survival and 48% overall survival (6). Once again, we would like to congratulate the authors for their excellent anatomic approach/surgery and for raising awareness of such a rare entity. Christos Iavazzo1, Panagiotis Peitsidis2,3, Ioannis D. Gkegkes4,5